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Q: How effective was the planned teaching program in altering mothers' knowledge of pediatric emergencies?

The planned teaching program was highly effective, as indicated by the shift from 63.75% of mothers having average knowledge pre-test to 82.50% displaying good knowledge post-test. This demonstrates a significant increase in knowledge regarding pediatric emergencies, emphasizing the program's success .

Q: How does the socio-economic status impact the nutritional and health conditions of slum dwellers in India?

The socio-economic status of slum dwellers significantly affects their nutritional and health conditions. Due to low socio-economic status, slum residents suffer from poor hygiene, inadequate sanitation, and insufficient nutrition, particularly among women and children, resulting in debilitating health conditions .

Q: What intervention strategies are suggested to combat the influence of fast-food marketing on child nutrition?

To counteract the effects of fast-food marketing, suggested interventions include implementing policies for nutritional labeling, taxing unhealthy food options, and promoting healthier alternatives like fruits and vegetables. Educating parents and regulating marketing practices can also mitigate adverse impacts on child nutrition .

Q: What role does fast-food marketing play in influencing childhood and parental behavior concerning nutrition?

Fast-food marketing significantly influences both children's and parents' eating behaviors by promoting fast-food consumption through targeted advertising. This marketing strategy often encourages the purchase of nutritionally poor food items, thereby contributing to obesity and related health issues .

Q: What statistical methods were used to evaluate the impact of exercise interventions on physical function and quality of life in different BMI groups?

The study utilized Repeated Measures ANOVA followed by Tukey Kramer multiple comparison tests to evaluate exercise interventions across different BMI groups. This approach assessed strength, endurance, flexibility, and quality of life improvements, showing a significant increase in post-exercise metrics with p values <0.0001 .

Q: What was the outcome of the therapeutic exercise program on pre-menopausal symptoms and quality of life among sedentary lifestyle women?

The therapeutic exercise program significantly improved pre-menopausal symptoms and quality of life as evidenced by the outcome measures used in the study, including the Menopausal Rating Scale (MRS) and SF-36 questionnaire. The pre and post-treatment analysis showed a statistically significant difference, with p values <0.0001, indicating the effectiveness of the program .

Q: What changes in knowledge levels regarding permanent pacemaker care were observed post-intervention in a selected patient group?

Post-intervention, there was a marked improvement in knowledge regarding permanent pacemaker care. Pre-test results showed 26% had poor knowledge, which improved significantly after the educational intervention, with 46% achieving a good knowledge level and none in the poor category .

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Volume 8 Number 4 October-December 2017

SCOPUS IJPHRD CITATION

SCORE
Indian Journal of Public Health Research and Development
Scopus coverage years: from 2010 to 2016 Publisher:
R.K. Sharma, Institute of Medico-Legal Publications
ISSN:0976-0245E-ISSN: 0976-5506 Subject area: Medicine:
Public Health, Environmental and Occupational Health
CiteScore
Cite Score 2015-
2017- 0.02
0.03
SJR
SJR 2017-
2015- 0.108
0.105
SNIP 2017-
SNIP 2015- 0.047
0.034

EMBASE
Indian Journal of Public Health Research & Development
EXECUTIVE EDITOR

Vidya Surwade
Associate Professor, Dr Baba Saheb Ambedkar,Medical College & Hospital Rohinee, Delhi
INTERNATIONAL EDITORIAL ADVISORY BOARD 3. Dr. Amit K. Singh, Associate Professor, Community
Medicine, VCSG Govt. Medical College, Srinagar – Garhwal,
1. Dr Abdul Rashid Khan B. Md Jagar Din, Uttarakhand
Associate Professor, Department of Public Health Medicine, Penang
Medical College, Penang , Malaysia 4. Dr R G Viveki, Prof n head,
Dept of Community Medicine, BIMS Belgavi
2. Dr V Kumar, Consulting Physician, Mount View Hospital, Las Vegas, USA
5. Dr. Santosh Kumar Mulage, Assistant Professor,
3. Basheer A. Al-Sum, Botany and Microbiology Deptt, Anatomy, Raichur Institute of Medical Sciences Raichur(RIMS) ,
College of Science, King Saud University, Riyadh, Saudi Arabia Karnataka
4. Dr Ch Vijay Kumar, Associate Professor, 6. Dr Gouri Ku. Padhy, Associate Professor, Community and Family
Public Health and Community Medicine, University of Buraimi, Oman Medicine, AII India Institute of Medical Sciences, Raipur
5. Dr VMC Ramaswamy, Senior Lecturer, Department of 7. Dr Ritu Goyal, Associate Professor,Anaesthesia ,
Pathology, International Medical University, Bukit Jalil, Kuala Lumpur Sarswathi Institute of Medical Sciences, Panchsheel Nagar
8. Dr. Anand Kalaskar, Associate Professor, Microbiology
6. Kartavya J. Vyas, Clinical Researcher, Prathima Institute of Medical Sciences , AP
Department of Deployment Health Research,
Naval Health Research Center, San Diego, CA (USA) 9. Dr.Md.Amirul Hassan, Associate Professor, Community Medicine
Government Medical College, Ambedkar nagar, UP
7. Prof PK Pokharel, Community Medicine,
BP Koirala Institute of Health Sciences, Nepal 10. Dr.N.Girish, Associate Professor, Microbiology, VIMS&RC,
Bangalore
8. Sajjad Salim Issa AL-Musawi
supervisor for student of the Arab board in family medicine 11. Dr BR Hungund, Associate Professor Pathology, JNMC
,Belgaum.
9. Prof. Dr. Ayad F. Alkaim, Professor of surface chemistry
and applications of nano-materials, Babylon University,Iraq 12. Dr Sartaj Ahmad, Associate Professor, Medical
Sociology, Department of Community Medicine,
10. Prof. Dr. Imad Hadi Hameed, Biomedical Science Swami Vivekananda Subharti University, Meerut, Uttar Pradesh, India.
Department,College of Nursing, University of Babylon, Hillah city, Iraq 13. Dr Manoj Kumar Tripathi, (Associate Professor),
11. Prof. Dr. Amean A Yasir, Department of Political Science and public administration,
Community, College of Nursing, University of Babylon, Swami Vivekananda Subharti University, Meerut, Uttar Pradesh, India.
Hillah city, Iraq 14. Dr Sumeeta Soni, Associate Professor, Microbiology Department,
B.J. Medical College, Ahmedabad Gujarat, India
NATIONAL EDITORIAL ADVISORY BOARD
Print ISSN: 0976-0245, Electronic ISSN: 0976-5506, Frequency:
1. Prof. Sushanta Kumar Mishra, Community Medicine,
Quarterly (Four issue per volume)
GSL Medical College – Rajahmundry, Karnataka
2. Prof D.K.Srivastava, Medical Biochemistry, Indian Journal of Public Health Research & Development is a
Jamia Hamdard Medical College, New Delhi double blind peer reviewed international journal. The frequency is half yearly
going to be quarterly by 2012. It deals with all aspects of Public Health including
3. Dr Sunil Mehra, Paediatrician & Executive Director,
Community Medicine, Public Health, Epidemiology, Occupational Health,
MAMTA Health Institute of Mother & Child, New Delhi
Environmental Hazards, Clinical Research, and Public Health Laws and covers all
4. Prof M.Sriharibabu, General Medicine, medical specialties concerned with research and development for the masses. The
GSL Medical College, Rajahmundry , Andhra Pradesh journal strongly encourages reports of research carried out within Indian continent
5. Prof Pankaj Datta, Principal & Prosthodentist, and South East Asia.
Indraprastha Dental College ,Ghaziabad The journal has been assigned International Standards Serial Number (ISSN)Print
6. Prof Samarendra Mahapatro, Pediatrician, ISSN: 0976-0245, Online ISSN: 0976-5506 and is indexed with Index Copernicus
Hi-Tech Medical College, Bhubaneswar, Orissa (Poland). It is also brought to notice that the journal is being covered by many
7. Dr Abhiruchi Galhotra, Additional Professor, Community and Family international databases. The journal is covered by EBSCO (USA), Embase,
Medicine, EMCare
AII India Institute of Medical Sciences, Raipur & Scopus database. The journal is now part of DST, CSIR, and UGC
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SS Institute of Medical Sciences & Research Center. Davangere, Karnataka Website: www.ijphrd.com
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not guarantee directly or indirectly the quality or efcacy of any product or service
Post Graduate Institute of Medical Sciences, Rohtak , Haryana
featured in the advertisement in the journla, which are purely commercial.
11. Dr Shailendra Handu, Associate
Professor, Phrma , DM (Pharma, PGI Editor
Chandigarh) Dr R K Sharma
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Control Programme, Logix Office Tower, Unit No. 1704, Logix City Centre Mall
Dte. DGHS, Ministry of Health Services, Govt. of India, Delhi. Sector- 32, Noida - 201 301 (Uttar Pradesh)
NATIONAL SCIENTIFIC COMMITTEE
Printed, Published and Owned by
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2. Dr. E. Venkata Rao, Associate Professor, Community Sector- 32, Noida - 201 301 (Uttar Pradesh)
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Published at
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Logix Office Tower, Unit No. 1704, Logix City Centre
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I

Indian Journal of Public Health Research &

Development
www.ijphrd.com

Contents
VVoolluummee 810N, October-DeceJmublye
uNmubmerb4er 7 r22001197

1. Effect of Therapeutic Exercises on Pre-Menopausal Symptoms in Sedentary Life Style Women ............... 1
A i s h w a r y a V . A h iw al e , S . A n a n d h , P r a n j al i G o s a v i
1. Dete n t io n , N e p o ti s m a nd T r u a n c y a s P r ed i c to r s o f W o r k p lace Deviance
in.....................................................................01
Se r v ice O r ga n iz at io n s : I n d ia 's E x p e r i en c e
2 . D oe s C o m m e rc i a l l y A v ai la b l e T o o th Brushes in India follow
Recommended
Sain aAthmMerailcisaentt yD, KenVtaals aAnsthsioKciuamtiaorni (ADA)
Norms? .............................................................................................. 6
V. Anu, N. SaiSwetha, C. Ramya, N. Ruksana, D. Ranjani
2. A Comparative Study of Satisfaction of Midwives and Mothers of Adherence to Patient Rights..................................07
M3a.r yMamaSteorhneailly ,MAokrratamliPtye yamt aan T, Berethieasrhyt eCh aTraeb aHrsoyspital in North India: A
4 Year Review ...................................... 11
Pratima Mittal, Garima Kapoor, Bindu Bajaj
3. Indian Diabetes Risk Score for Screening of Undiagnosed Diabetes...................................................................................13
4 . D o se R es p o n s e R e la t io n s h i p o f C h i ld C e n tered Task Oriented
In d i v id u a l s o f E lu r u C i ty , A n d h r a P r a de s h , I nd i a
Training in Children with Cerebral Palsy-
A Randomized Controlled Study. Study Protocol ....................................................................................... 17
Chandrasekhar Vallepalli, K Chandra Sekhar, U Vijaya Kumar, P G Deotale
Kovela Rakesh Krishna, Dhanesh Kumar K U
4. A5w. aAresnseoscsiaatnidonP rbeedtwicteoerns oOfbPeCsiOtyD aanmd oEnlgevUantedde rBgrlaodouda

PtereSstsuudreen atsm.o..n...g.. .S...c..h..o..o...l. .G....o..i.n...g.. .A...d..o...l.e..s..c..e..n..t..s..–...................18

CAn nAM CarroysNs Selesocnti,oLneakhl aSVtuisdwya
n..a..t.h..,.A...n..j.u...P..h.i.l.i.p...T.................................................................................................... 21
Lipilekha Patnaik, Sumitra Pattnaik, Trilochan Sahu, E. Venkata Rao, Saswatika Beura
5. The Effectiveness of Mindfulness on the Reduction of Anxiety...........................................................................................23
an6d. TDheep rEesffseiocntivoef nDeisvso rocfe Cd oWnostmraeinnt-Induced Movement Therapy and Placing
Technique of Bobath on
Yasa mUipnpHero jLatiimfarb, MFuinnacHtioosne iinn ZHaedemh,ipFaarreibtoicrz
IDndorivtaijdual ........................................................................................ 25
Manali N. Hanphode, G. Varadharajulu, Suraj Kanase
6. A Study on Clinical Profile and Trend in Suicide Attempters in Psychiatry Consultation...............................................28
7. Effect of Manual Positioning as an Adjunct to Intercostal Drainage tn Hydropneumothorax .................... 31
D Naveen Kumar
Monali M. Kashyap, Javid Hussain Sagar, G. Varadharajulu
7. A8S.t uEdffyecotf oOfr gManooto-pr hCoosnpthroorlo TursaCinoimngp ooun nIdsoPlaotiesodn Linugmwbiathr

SRteafbeirleinzceer taon..d.. .C...o...r.e.. .M....u...s..c..l.e.. .T...r.a..i..n..i.n...g.. .i.n... .................33

Bloo Cd hSruognairca LnodwP sBeuadcko cPhaoilnin Pesatteieranstes
L..e..v..e.l.s......................................................................................................... 37
NithiNnakummraartaS PK.aMdakaonl,eS, uGn.ilVkaurmaadrhSaBrairjaudlaur,, SSmanitdheaeMp ,SMhianlldikearjun
KBiradar

8. Pr9e.v aElenntecreporfisIen tGesatminiafil cPaatriaosnit:i Ac I MnfeocttiivoantsioinnaSlc Dhoroivl eG aoti

n g oCrhkipldlarceen .i.n.............................................................................................................................................3 473
W
RuraPl.ASr.eBasuvoaf nHeaspwuarrDi, iMstriSctS, wUePt,hIandia
KamyaVerma, Krati R Varshney, Sanjeev Dimri, S P Garg
10. Design and Implementation of Performance ImprovedMedical Signal Filters with and without Multiplier 49
P.Saravanan, B. Latha, K. Bhoopathy Bagan
9. Study of Osteoporosis in Women of Malwa Region of Punjab............................................................................................41
V1e1e.r eEnffdreacCt ohofu Idnhpaartyient Physiotherapy Intervention Versus Delayed Outpatient Physiotherapy
Intervention in Post Stroke Hemiplegic Individuals ................................................................................... 56
10. The PEfrfaegctaivtieVn.esSsaoluf nMkihned,fGul.nVeassr-aBdahseadraGjuroluu,pSTuhrearjaKpyanoansRe
educing Internet...............................................................44
Addiction and Increasing the General Health of Adolescent Girls
12 . E ff e c t o f T h e r a p eutic Intervention and Hand Muscle Training on Pain and Quality of
N as r in R a h i m i Sh a d b a d
Hand
Function in Subjects with Chronic Tennis Elbow ....................................................................................... 61
11. RolePorfaSnoacliialDSeuspapi,oGrt .aVnadrCadophianrgajSutylule, sSimn iMtaeKntaanl aHseea, lSthanodf
eWeopmSehninWdeho Apply for Divorce..................................49
Farhad Asghari, Hajar Ramazannia
22

13. Assessment of Balance in Children with Developmental Coordination Disorder in Indian Context ......... 67
U. Ganapathy Sankar, R.Monisha

14. A Comparative Study to Determine the Effectiveness of the Taping and Mulligan’s
Mobilization with Movement Techniques on Pain in Knee Osteoarthritis ................................................. 71
Balaji R. Pawar, A. Jeganathan, R. Monisha

15. Perception of Undergraduates and Postgraduates of the Scope of Periodontics ......................................... 76

F. Mariyam Niyas, Radhika Arjunkumar

16. Correlation between the Nature of Toothpaste and the Prevalence of Brushing Habits of
Children Residing in Chennai ..................................................................................................................... 83
Rinieshah Nair R. Baskran, Deepa Gurunathan, Madhusudhan Vasantharajan

17. Effect of Structured Therapeutic Exercises Protocol on Physical Functional Status in

Women with Varying BMI .......................................................................................................................... 88
Ruchita R Shah, S. Anandh, G. Varadharajulu

18. Effect of Choice-Based Sensory Stimulation as a Coma Stimulation Technique on Traumatic Brain Injury 94
Sayli D. Deshpande, G. Varadharajulu, Suraj Kanase

19. Knowledge Attitude Practice on the Oral Hygiene Practices in Children Below 12 Years ...................... 100
Shivani N, Revathy Gounder

20. Role of Tumour Necrosis Factor Alpha (TNF-α) in Pulmonary Pathophsiology of Chronic
Obstructive Pulmonary Disease ................................................................................................................ 105
Smriti Gupta, Ajit Kumar, Vishwajeet Rohil, Anuj K. Bhatnagar

21. Effect of Closed Kinematic Chain Exercises on Distal Muscle Weakness in Post Guillain Barre Syndrome 111
Sneha G. Narlawar, G. Varadharajulu, Suraj Kanase

22. Rugoscopy: An Adjunctive Diagnostic Tool for Malocclusion? ............................................................... 117

Swapna B V, Sheetal Shetty, Smitha S Shetty

23. Effect of McKenzie Approach and Neck Exercises on Forward Head Posture in Young Adults ............. 123
Vishnupriya Deshpande, Khushboo Bathia, Smita Kanase, Amrutkuvar Pawar, Prachi Jain, Gatha Patel

24. Socio-economic, Hygiene and Nutritional Status of Indian Slums: A Scoping Review ........................... 128
K. Jansi Rani, S. Kavitha Maheswari, Sebastian Kot, A. Hariharasudan

25. Study of Correlation between Serum Lipid Profile and Thyroid Function in a Tertiary Care Hospital .... 133
Aryankumar, Ajit Sontakke, Sangita Patil, Dhirajkumar Mane

26. Self Management and Knowledge among People with Type 2 Diabetes .................................................. 139
Aldrin Vas, Elsa Sanatombi Devi, Sudha Vidyasagar

27. Anti-Inflammatory Activity of Silver Nanoparticles Prepared from Ginger Oil—An Invitro Approach . 145
M. Maajida Aafreen, Roy Anitha, Rachel Christina Preethi, S. Rajeshkumar, T. Lakshmi

28. Comparative Evaluation of Maximum Bite Force and Facial Morphology—A Cross Sectional Study ... 150
Shweta Tiwari, Arathi Rao, Ramya Shenoy, Suprabha BS

29. Comparative Evaluation of Tensile Bond Strength and Shear Bond Strength of Mineral Trioxide
Aggregate with Composite Resin and Resin Modified Glass Ionomer ..................................................... 156
Radhakrishnan S, Arathi Rao, Ramya Shenoy, Suprabha BS
30. A Study to Assess the Effectiveness of Planned Teaching Programme on Knowledge Regarding
Prevention of Abuse among the Children of 11–14 Years of Age at Selected Schools of Sangli,
Miraj, Kupwad Corporation Area .............................................................................................................. 163
Bhavana Cristopher Samson, Manisha Sunil Kulkarni
31. Risk Factors Associated with Overweight and Obesity among Population of Ahmedabad, India ........... 168
Bhoomi Arora, Snehal S. Patel, Banshi Saboo
32. Fast-Food Marketing and Children’s Fast-Food Consumption: A Trigger to Childhood Obesity ............ 173
Binkey Srivastava
33. Retina Identification System Using Machine Learning and Multiple Regression Model ......................... 178
D. Nagarajan, R. Sujatha, J. Kavikumar, Udaya Mouni Boppana, Dhivyapriya
34. Breast Cancer Prediction Using Ensemble Techniques ............................................................................. 183
G. Manikandan, B. Karthikeyan, P. Rajendiran, R. Harish, T. Prathyusha, V. Sethu
35. Effects of Pesticides on Lung Function Test in Farmers of Satara District, Maharashtra, India ............... 186
Gauri Joshi, A. G. Joshi, S. N. Patil, Ajit Sontakke
36. A Study to Assess the Effectiveness of Planned Teaching Program on Knowledge Regarding the
Care of Permanent Pacemaker at Home among Patients at Selected OPDs of Sangli and Kolhapur City 192
Jesica Dileep Mali, Sunil. Kulkarni
37. A Study to Assess the Effectiveness of Planned Teaching Programme on Knowledge Regarding Selected
Pediatric Emergencies among Mothers of Under Five Children at Selected Anganwadi’s of Sangli,
Miraj and Kupwad Corporation Area ........................................................................................................ 195
Jesica Prashant Malap, Shaila Mathew
38. Comparative Evaluation of the Effect of Radiation Therapy on Surface Micro Hardness of Three
Restorative Materials—An in Vitro Study ................................................................................................ 200
Karthik Shetty, Mary Byju, Chong Hao Phin, P U Saxena, Challapalli Srinivas
39. Evaluate the Association between Acrochordons and Systemic Diseases ................................................ 205
Malar Mangai E., Harsha Vardhan K., Bhuvanarachagan A.
40. The Logical Investigation of the Digitalization andits Capacities, Particularly those Influencing
Conduct in Human Brain Research on Based on the Psychological Distress ........................................... 210
Nandita Sikari, K HariKrishnan

41. To Study Behavioral and Socio Economic Factors of Non Communicable Diseases in
Northeast India Using NFHS-4 ................................................................................................................. 214
Phrangstone Khongji

42. A Study to Assess the Knowledge and Self Reported Practices Regarding Care of Arterio Venous
Fistula among Patients at Selected Haemodialysis Units of Sangli City .................................................. 220
Pratik N Amrao, Swati C. Kurane

43. A Study to Assess the Effectiveness of Topical Application of Honey on LSCS Wound Healing among
Postnatal Mothers from Selected Maternity Hospitals of Sangli, Miraj and Kupwad Corporation Area 223
Priti D Khade, Archana Dhanawade

44. A Study to Assess the Level of Burden and Coping Strategies among Caregivers of Patient with
Affective Disorders at Selected Hospitals of Sangli, Miraj, Kupwad Corporation Area .......................... 228
Ramesh Giramalla Honamore, Narayan K Ghorpade
45. Factors Affecting Awareness and Perception of Youth Regarding the Public Health and Hygiene
Related Campaigns though Social Marketing ........................................................................................... 233
Roktim Sarmah, Dheeraj Nim

46. Three Stepped Approach to Screening of Cervical and Breast Cancer among Rural Women .................. 239
Asha K. Pratinidhi, Radhika Joshi, Vaishali Vhawal, Pandurang Chougule, Sunita Tata, Satish Kakade

47. Single-Visit versus Dual-Visit Endodontics—A Comparative Study ....................................................... 244

Sanjay M Londhe SM, Sonali Sharma, Sheetal Lal

48. A Study to Evaluate the Effectiveness of Ginger Tea on Morning Sickness among Antenatal
Mothers in Selected Area of Sangli, Miraj, Kupwad, Corporation ........................................................... 251
Seema D Shiradwade, MS. Regina Satvekar

49. Contraceptive Methods: Knowledge, Practice and their Attitude among the Women of Rural
Population in and around Bangaluru City of Karnataka State, India ........................................................ 257
SenigalaKuruba Anusuya, Sudha Patil

50. Comparison Prophylactic Glycopyrrolate, Dexamethasone, Metoclopramide in Control of

Nausea and Vomiting after Spinal Anaesthesia for Caesarean Delivery ................................................... 261
Gautam Malhotra, Suresh Y. V., Anupama Suresh Y, Shaik Gulam Osmani, Kavya Prabhu

51. A Study to Assess the Effectiveness of Eucalyptus Oil on Knee Pain among Osteoarthritis Patients in
Selected Areas of Sangli, Miraj and Kupwad Corporation ....................................................................... 267
Siddhant N. Shirgaokar, Pravin Dani

52. A Study to Assess the Knowledge Regarding Self-Care Management among the Pregnant Mother with
PIH Attending Selected Maternity OPD’s of Tertiary Hospitals in Sangli, Miraj and
Kupwad Corporation Area ......................................................................................................................... 272
Silviya John Gaikwad, Vijaya Kumbhar

53. A Study to Assess the Relationship between Job Satisfaction and Burnout among Staff Nurses
Working in Selected Hospitals of Sangli, Miraj and Kupwad Corporation Area ...................................... 277
Umesh Kisan Rathod, Satish Salvi

54. A Study on Awarness among Employees on Health Care and Appraisal System Adopted in
Pharmacy Companies ................................................................................................................................ 281
S. Poongavanam, S. Jivita

55. A Study on Impact of Occupational Health and the Changing Business Scenario of Corporate Appraisal 285
S. Poongavanam, S. Jivita

56. An Empirical Study on Employee Health and FIRO-B Relationship ....................................................... 289
S. Poongavanam, K. Viswanathan

57. An Empirical Study on Environmental Hazards and Recruitment Process in

Health Care Compnies, Chennai ............................................................................................................... 293
S. Poongavanam, K. Viswanathan

58. Impact of Health Care Laws and Employee Relationship, Policies in Pharma Companies–A Study ...... 296
S. Poongavanam

59. Antioxidants and Antibodies in Structural Thyroid Diseases ................................................................... 299

Anita P Javalgi, B R Yelikar, Kusal Das
60. Enhancement of Facial Aesthetics and Function in Posteriorly Edentulous Mouth:
An Orthognathic Surgical Case Report ..................................................................................................... 305
Ashith M. V., Mustafa Khader, Utkarsh Mangal, Mithun K

61. A Study on Development of Processes for Verification and Validation in Medical Device Domain ........ 312
P. Shireesha, P. Niranjan

62. A Technique for Network Design and Requirements for Medical Sensors ............................................... 317
V. Chandra Shekhar Rao, P. Niranjan, A. Sowmikadurga

63. Breast Self-Examination and Clinical Breast Examination: Knowledge, Practice, and Awareness
Towards Breast Cancer among Females in and around Mangaluru .......................................................... 323
Sadhwi, Gayathri M Rao, Aradhana M, Saritha Kamath U

64. Emotional Intelligence Level of Students and Mental Ability Belonging to Rural and Urban Backgrounds 329
Shailaja Sangaraboina

65. Caries Risk Profiles of Rural and Urban 12 Year Old School Children in Mangalore Using the Cariogram 334
Jyotsna Malhotra, Ashwini Rao, Ramya Shenoy, Mithun Pai BH

66. Role of Trust and Privacy Concerns towards Usage of E-Health Services—
An Extension of Expectation-Confirmation Model ................................................................................... 339
K Anil Kumar, Subhashree Natarajan

67. Risk Factors Associated with Onset of Neck Pain: A Review .................................................................. 346
Neha Gupta, Aparna Sarkar, Deepak Kumar

68. Prediction of COPD Using CT Measurements of Pulmonary Artery and Aortic Diameter ...................... 352
Priyanka, Abhijith A, Adarsh Veer Sisoudiya, Saikiran Pendem

69. Acute Anticonvulsant Activity of Diltiazem, Nimodipine and Flunarizine in Wistar Albino Rats by
Maximum Electroshock-Induced Seizure ................................................................................................. 357
Saniya K, BG Patil, Madhavrao, Prakash KG

70. Isolated and Combined Effect of Plyometric and Weight Training on Selected Physical Fitness and
Hematological Variables of Football Players ............................................................................................ 362
K. S. Saran, K. Vaithianathan, Mithin Anand, T. Arun Prasanna

71. Effect of Game Specific Circuit Training and Plyometrics on Selected Physiological and
Hematological Variables of Handball Players ........................................................................................... 365
Mithin Anand, K. Vaithianathan, K. S. Saran, T. Arun Prasanna

72. “A Study to Assess Coping Stratergies among Parents of Mentally Challenged Children at Selected
Special Schools of Miraj, Kupwad and Kolhapur Corporation Area” ...................................................... 368
Akshay Bhupal Pawar, Rajesh Gaikwad

73. Effectivness of Curry Leaves Powder on Blood Sugar Level among Diabetic Patients ........................... 373
Kunal V Jadhav, Basavant Dhudum

74. A Framework Analysing Patient Adherence Level in Cardiovascular Disease in Delhi-NCR Region .... 379
Navjot Kaur, Supriti Agrawal, Hemendra Gautam

75. A Study to Assess the Effect of Pineapple Extract on Episiotomy Wound Healing among Postnatal
Mothers in Selected Hospitals of Sangli, Miraj and Kupwad Corporation Area ...................................... 384
Sindhu R.Gaikwad, Nilima R. Bhore
76. Assessment of Clinical Profile of Patients with Blunt Abdominal Trauma Admitting to
Emergency Department ............................................................................................................................. 389
Ashok Y Kshirsagar, Pratik D. Ajagekar, Ajay Aggarwal, Shekhargouda Deshetti

77. Comparative Study of Semen Analysis in Fertile and Infertile Males ...................................................... 393
Joy A K Ghoshal, Anil Kumar Reddy

78. Recharging Ground Water using Age–Old Traditional Mechanisms ........................................................ 399
Manbeer Kaur, Mona Prashar

79. MRI Image Training and Finding Acute Spine Injury with the Help of Hemorrhagic and
Non Hemorrhagic Rope Wounds Method ................................................................................................. 404
Sk Hasane Ahammad, V Rajesh, N Hanumatsai, A Venumadhav, NSS Sasank, KK Bhargav Gupta, Syed
Inithiyaz

80. Cloud Computing Based Diagnosis for Cancer Detection ........................................................................ 409
Syed Shameem, Surya Teja S, Anoop P, Pavan Kalyan R, Vijay V, P. S. Srinivas Babu

81. A Cross-Sectional Study to Assess the Knowledge about Prevention and Home Management of
Diarrhoea among the Mothers of Under Five Children in an Urban Area of Amritsar, Punjab ................ 415
Amanpreet Kaur, Harpreet Kaur, Harpreet Kaur, Priyanka Devgun

82. A Study to Assess the Parents Satisfaction Regarding Pediatric Care Services Rendered by Staff
Nurses from Selected Pediatric Units of Sangi City ................................................................................. 421
Karishma D. Mulla, Aparna Kale

83. Effect of Depression on Treatment Outcome in Multi-Drug Resistant Tuberculosis Patients Under
Programmatic Management of Drug Resistant TB Services in Amritsar, Punjab ..................................... 427
Manisha Nagpal, Naresh Chawla, Priyanka Devgun

84. Incidence of Pulmonary and Extrapulmonary Tuberculosis among Jaintia Tribes, Meghalaya:
A Hospital based Study ............................................................................................................................. 433
Arpita Mitra, Roumi Deb

85. An Automatic Disease Early Prediction and Diagnosis Recommendation Framework for Brain Tumours 438
Nandan Bodapalli, Kunjam Nageswara Rao, Parada Vara Prasad Dora

86. Does Right Hand Second Digit to Fourth Digit Ratio Correlate with Primary Infertility in Males? ........ 444
Narendran Krishnamoorthi, Nikhil Shetty, Nandita Shenoy, Ashok Shenoy, Christopher C
Pais, Muralidhara Yadiyal

87. Prevalence and Characterization of Opportunistic Candidal Infection among Patients with Type II
Diabetes Mellitus ....................................................................................................................................... 448
Sandhya Rani T., R. Srikumar, E. Prabhakar Reddy, S. Latha

88. Child Life Program Through Drawing Play Activity as Efforts to Minimize Stress Hospitalization in
Children with Leukemia ............................................................................................................................ 454
Yuni Sufyanti Arief, IlyaKrisnana, Praba Diyan Rachmawati, Nursalam, IDG Ugrasena, Shrimarti R. Devy

89. The Correlation between Diabetes Status and Hair Loss among Aged Women in Alor Setar Area ......... 459
Thin Thin Aung, Fatin Farhana Binti Shahnon

90. Differences in Caries Prediction Test of Cariostat and Plaque Formation Rate Index (PFRI) on Children 465
Prima Nerito, Boy Sandy Sunardhi, Tito Yustiawan
91. Customers’ Service Expectations in Dental Hospital: Using Servqual Model ......................................... 470
Firdauzi Rimadhan, Devita Tintasari, Fredy Mardiyantoro

92. The Nurse’s Work Culture Relationship with the Quality of Nursing Service Between the Government
Hospital and Private Hospital: Comparative Study in 2018 ...................................................................... 475
Dilgu Meri, Meri Neherta, Zifriyanthi Minanda Putri

93. Relationship of Hand-Hygiene Compliance Score with Nurse’s Engagement in Intensive Care Unit ..... 480
Boy Sandy Sunardhi, Prima Nerito, Tito Yustiawan

94. Development of Management Skills Head of Public Health Center Based on Analysis of
Management Skills Theory of Cameron and Quinn .................................................................................. 484
Martha Wahani Patrianty, Nyoman Anita Damayanti, Tito Yustiawan

95. Assessment of the Anatomical Causes of Persistent Nasal Obstruction after Primary Septorhinoplasty . 490
Salim Hussain Ibrahim

96. Diagnosis of Trichomonas Vaginalis Infection by Detection of Glutaminase (Glut) Gene by Nested PCR 496
Faten Ahmed Hassan, Huda Dhaher Al-Marsomy, Suhad Asaad Mustafa

97. Burnout Syndrome among Physicians Working in Primary Health Care Centers in Baghdad,
Al-Rusafa Directorate, Iraq ....................................................................................................................... 502
Abdul Munem Al Dabbagh, Ali Hassan Hayyawi, Maha Saber Kochi

98. Influence of Low Power He-Ne Laser on the Skin Thickness of Swiss Mice .......................................... 508
Zainab Abd ALjalil, Ali Kamel Mohsin, Ali Mahdi Mutlag

99. The Effect of Electric Stimulation in the Development of the Explosive and Speeding Ability of the
Arms to Achieve the High Snatch of the Weightlifters Karbala Youth Club ............................................ 515
Alaa M. Dhahir

100. Monte Carlo Simulation to Estimate the Male and Female Effective Dose due to Radon Exposure in Al-Najaf 520
Mokhalad Ali Zbalh, Hussien Abid Ali Bakir, Ali Abid Abojassim, Adhraa Baqir Hassan

101. Impact of Material of Water Storage Tanks on Bacterial Quality in Shualat Al-Sadrain City in Baghdad 525
Amel Mustafa Kamil, Khadeja Shaaban Hasan, Sajad Mahdi Hasan

102. A Descriptive Study on Pulmonary Tuberculosis in Salahaddin Governorate, Iraq ................................. 531
Hasan Ismail Sultan, Noor Alhudaa Sadoon Khalaf

103. The Relation between Homocysteine, Oxidative Stress and Atherosclerosis Disease .............................. 537
Ekhlas Abdallah Hassan

104. Comparison of the Educational Effect of Two and Three Dimensional Books on Dental Anxiety in
Children with Hearing Impairment (Aged 7–9 Years) .............................................................................. 543
Eva Fauziah, Selvyra Rachmawati, Aprillia Puspita Rachmadani, Cahyanti Wydiastuti Susilo

105. Effectiveness of an Education Program for School Age Children Related to Management of Growth
Hormone Deficiency University of Baghdad-College of Nursing ............................................................ 547
Fatima H. Abbas, Eqbal GH. Ma’ala

106. The Impact of Smart Phones on Musculoskeletal Pain on Students in Tikrit University ......................... 553
Firas Tariq Ismaeel
8 8

107. Risk at the Educational Laboratory in Indonesia ...................................................................................... 558

Frida Qurbasari D., Putri Ayuni Alayyannur, Dani Nasirul Haqi, Meirina Ernawati, Fauziah Mukti Sugiharto

108. Split Face Comparative Study of the Efficacy and Outcome of ND: YAG Laser and Intense
Pulsed Light System for Hair Removal ..................................................................................................... 563
Haider Al-Sabak, Muhsin Al-Dhalimi, Eman Mohammed

109. C-reactive Protein and its Relationship with Lipid Profile in Suicidal and Non Suicidal Adults with
Major Depression ...................................................................................................................................... 569
Hassam M. Al-Amarei, Suaad Mohammed H. Rasheed, Ali J. Eidan

110. Considered Absorption Spectra for Identification of Blood Constituents ................................................. 574
Hassan Abdullah Mahdi, A. A. Al-Rubaiee, Muhanad M. Azzawi

111. Evaluation of the Concentration of Some Heavy Elements of Selected Soils from Shatrah City ............ 578
Ibtihaj Ahmed kadhim, Mohammed Abdulabbas Hasan

112. The Effect of Theory of Planned Behavior Models to Behavior of Cadres as the First Aiders of Stroke Attacks
584
Imelda Feneranda Seravia Tambi, Yuyun Yueniwati, Setyoadi

113. Factors Associated with Women’s Treatment for Urinary Incontinence in Hasan Sadikin Hospital ........ 590
Indra Gazali Syamsudin, Karina Shasri Anastasya, Benny Hasan Purwara, Edwin Armawan, Jusuf
Sulaeman Effendi, Budi Handono, Hadi Susiarno

114. Histopathological Changes in the Liver and Kidney of Albino Mice on Exposure to Zinc Toxicity ....... 596
Ishraq J. Hassan, Ihsan S. Sahi

115. Microbial Inhibition to Water Hyacinth (Eichhornia Crassipes [Martius] Solms-Laubach) in

Abu Zirk Marsh by Using Selected Fungi ................................................................................................. 601
Jameelah Wthaij Ogali Al-Yosef, Abdul-Rahman Abduljabbar Al-Kubasi, Ihsan Flayyih Hasan Al-Jawhari

116. Complications and Lipid Parameters Status among 50 Years and above Age Group Hypertension
Population at Primary Health Care Centres of Buraidah City ................................................................... 606
Asim Fahad AlKhalifah, K. Chandra Sekhar, Abdulaziz Sulaiman Alsaif, Alya fahad Alkhalifah

117. Cardiac Failure in Misan, Iraq ................................................................................................................... 612

Khalid Obaid Mohsin

118. Dilated Cardiomyopathy in Children ........................................................................................................ 616

Khalid Obaid Mohsin

119. Effect of Exercise and Body Mass Index (B.M.I.) on Fitness ................................................................... 621
Khalidah Nayyef Mustafa

120. Analysis of Related Factors with Anxiety Occurrence in Population with the Risk of
Coronary Heart Disease in Indonesia ........................................................................................................ 626
Titin Andri Wihastuti, Fajaruddin Fajaruddin, Tina Handayani Nasution, Kumboyono
Kumboyono, Yulia Candra Lestari

121. What are the Staffing Levels and Maternal Outcomes? A Descriptive Study in Referral Hospitals in
Java, Indonesia .......................................................................................................................................... 631
Makhfudli Makhfudli, Ferry Efendi, Anna Kurniati, Retnayu Pradanie, Susy Katikana Sebayang
122. Estimation of Procollagen Type III Peptide (PIIIP) Level in β Thalassemia Patients .............................. 637
Maryam Kadhim Al-Shemery, Arshad Noori Al-Dujaili

123. Study Prevalence of Breast Cancer and the Relation it’s with Some Risk Factors and Blood Group in
Al-Najaf Governorate, Iraq ....................................................................................................................... 643
Maysoon K.A. AL-Hadrawi, Noor Ibrahim, Esaam Mohmmed Turky, Noor Ismeal Nasser, Ali k. Meetab

124. Strengthen the Spiritual-Based Family Resilience to Overcome the Family Stigma of Leprosy ............. 647
Nasrudin, Ah Yusuf, Rachmat Hargono, Tjipto Suwandi

125. Association between Socio-economic Status and Breast Feeding Practices in a Group of Women
Delivered During the Previous Year in Kirkuk City ................................................................................. 653
Nazar Ahmed Mahmood, Qasim Husein Mohammad, Kasim Sakran Abass

126. Quantitative Assessment of Factors Affecting Visual Acuity by Changing the Luminance ..................... 658
Osama Q. Abdullah, Fadia W. Al-Azawi, Sara T. Hassan

127. Effect of Adding Probiotic with Different Levels of Citric Acid in Feed Supplementation to Laying
Hens on Bacteria Content of Feed, Litter and Egg Shell .......................................................................... 663
Rashid H. hameed Al-Dalawi, Qana Hussein ameen, Mahdi Salih Jasim

128. Occurrence of MBLs and Carbapenemases among MDR and XDR Acinetobacter baumannii
Isolated from Hospitals in Iraq .................................................................................................................. 668
Safa Hasan Radhi, Alaa H. Al-Charrakh

129. The Effect of the Adding Ganoderma Lucidum Fungus Powder in the Production Performance for the
Brown Japanese Quail Bird ....................................................................................................................... 675
Samawal S. Al-Tikriti, Abdul Haq Ismail Al-douri

130. Effect of Non-pharmacological pain Management Methods on Reduction the Severity of Labor Pain in
Primigravida Women at AL-Elwyia Maternity Teaching Hospital ........................................................... 680
Sarab Nasr Fadhil, Rabea Mohsen Ali

131. Cholera Outbreak in Iraq, 2017 ................................................................................................................. 686

Shakir Mohsen Zgheir, Nabil Mansur Mustafa, Ali Abdalkader Ali, Jawad Al-Diwan

132. White Blood Cell, Procalcitonin, C-Reactive Protein and TNF-α as Prognostic Factors in Pediatric Sepsis 692
SittiAizah Lawang, Idham Jayaganda, Dasril Daud

133. Reactive Thrombocytosis after Caesarean Section and Normal Vaginal Delivery: Implications for
Maternal Thromboembolism and its Prevention ....................................................................................... 698
Suha Abduljaleel Wadi, Ahmed Rifat Shakr, Farah Muayyed Gebriel Shammas Youisif

134. The Impact of Hormonal Replacement Therapy on Herpes Simplex Infection and Gingival Health in
Post-Menopausal Women .......................................................................................................................... 705
Suzan Mohammed Abdul Raheem, Esra Hassan Abd Ali, Mahmoud M A Elian

135. The Relationship between Neck Pain and Hand Dexterity among Violinists in Kota Kinabalu,
Sabah, Malaysia ......................................................................................................................................... 710
Tay Xin Le, Rajkumar Krishnan Vasanthi, Jim Brown Clement

136. Antibiotics Usage and Their Cost in the Pediatric Wards of Salah Aldin Teaching Hospital ................... 716
Thikra M. Al-Kumait, Emad Maaroof Thakir, Hind Mutar Ibrahim, Alaa H. Alwan
137. Education Conducted By Pharmacist in Improving Hyperlipidemic Patient Adhearance ........................ 723
Vidia Arlaini Anwar, Delina Hasan, Sesilia Andriani Keban, Yardi Saibi

138. The Effect of Exercise Technique Altering with Use Heavyweight Rackets in the Development of
Concentration (Sodium, Potassium) in the Blood and Smash Skill for Player’s Badminton ................... 729
Wissam Salah Abdul Hussein, Abeer Ali Hussein, Ebtighaa Mohammed Qasim

139. Evaluate the Level of Application of Sports Marketing Practices for the First Iraqi Football Clubs ....... 734
Yaseen Ali Khalaf, Ibrahim Younis Waga

140. Knowledge, Attitudes, and Behavior of Pregnant Women in Preventing of Pregnacy Complication and
Childbirth: Application Study of Yudhia Model ....................................................................................... 740
Yudhia Fratidhina, Nina Herlina, Desri Suryani, Yandrizal

141. Intra and Inter-Rater Reliability of Web Plot Digitizer Software in Quantifying Head Posture Angles ... 745
Yughdtheswari Muniandy, Devinder Kaur Ajit Singh, Suresh Mani, Baharudin Omar

142. Proton Pump Inhibitor to the Hepatic Cirrhosis Patients with Hematemesis Melena: A Retrospective Study 751
Zakiyah, Didik Hasmono, Muhammad Noor Diansyah, Christiawan Ardianto

143. Acceleration of Socket Healing by Using Placental Collagen with BDNF: Radiological and
Histological Studies ................................................................................................................................... 758
Athraa Y. Al-Hijazi, Imad K. Abbas Al-Rifae, Zaid M.Akram, Luay Nafaa Kaka

144. Study the Effect of Lycium barbarum Polysaccharide on Bone and Thyroid Gland in Hyperlipidemic
Healthy Male Albino Rats ......................................................................................................................... 764
Heba A. Abd-Alsalam Alsalame

145. Effect of Exposure Biochinin-A During Gestation Stage on HoxA10 Gene Expression and
Histological Change in Uterus of Healthy Female Rats ............................................................................ 769
Huda A. Najy, Ayyed H. Hassan

146. Prevalence and Associated Risk Factors of Forward Head Posture among University Students ............. 775
Vinodhkumar Ramalingam, Ambusam Subramaniam

147. Exploration of Patients Value as in Accordance with Bugis Philosophy in Public Hospital at the
Sulawesi Selatan, Indonesia ...................................................................................................................... 781
Armin, Indahwaty Sidin, Indrianti Sudirman, Harun Achmad

148. Validation of the Emotional Competency Module .................................................................................... 787

Asma Perveen, Nurul Ain Hidayah Abas, Hazalizah Hamzah, Pau Kee, Ebru Morgul, Fauziah Binti
Mohd Sa’ad, Pavithrah Jaya Kumar

149. Community Led Total Sanitation (CLTS) in Cikupa Village and Teluknaga Village in Tangerang, Indonesia
792
Devi Angeliana Kusumaningtiar, Gisely Vionalita

150. The Prevalence of Explained and Unexplained Subfertility—A Case Study: Kirkuk City (Iraq) ............ 797
Eman I Fathi

151. Cellular Immunity of River Water Consuments and Bandarmasih Municipal Waterworks Consuments 802
Huldani, Bayu Indra Sukmana, Rahmiati, Anindya Pujiningtyas, Eldha Savitri, Fauziah, Ummi Nihayah

152. Role of Sentinel Lymph Node Biopsy in Staging of Early Endometrial Cancer ...................................... 808
Mohamed Soliman Elmahdy, Gamal Abdelhalim Amira, Mohamed Abdelfatah ElZohairy, Abdelhamid
Mohamed ElKalawy, Zeiad Samir Gad, Eman Naguib Khorshed
153. Inorganic Nitrogen Salts in Fibrinolytic Enzyme Production from Bacillus Megaterium BM 9.1 with
Solid State Fermentation ........................................................................................................................... 813
Mukti Hapsari, Achmad Toto Poernomo, Amiruddin Prawita

154. Relationship Exclusively Giving Mother’s Milk with Growing Baby ......................................................819
Mustamin Mustamin, Chatarina Umbul, Shrimarti Rukmini Devy, Rudy Hartono

155. Application of Community Models in an Effort to Control Smoking Behavior .......................................824

Ria Rezeki Sudarmin, Andi Zulkifli, Masni, Suriah, Habibi, Helmy Gani, Muhammad Azrul Syamsul

156. Level of Type L Metacrylate Acid Copolymer as Microparticle Matrix Improves Lactobacillus casei
Protection against Gastric Acid ................................................................................................................. 829
Ayun Dewi Rahayu, Dwi Setyawan, Sugiyartono

157. The Influence of Tell Show Do Method Based on Individualized Educational Program (IEP) to the
Tooth-Brushing Behavioural Change among Slow Learner Children in Bukittinggi, Indonesia ............. 835
Febrian, Ghina Ukhtia Fajrani, Arymbi Pujiastuty

158. Hyperglycemic and Hypertension are Major Component of Metabolic Syndrome that Caused
Circulatory Morbidity in Hajj Pilgrims ..................................................................................................... 839
Iche Andriyani Liberty, Nasrin Kodim, Mukaramah

159. The Determinant Factors of Child’s Immunization Status: A Cross Sectional Study on the
Dayak Pitap Tribe in the District of Balangan Indonesia ......................................................................... 845
Ida Hastutiningsih, Oedojo Soedirham, M. Bagus Qomaruddin, Boerhan Hidayat

160. The Use of Diuretic Drugs in Heart Failure Patients ................................................................................ 851
Lolla Junny Avianda, Didik Hasmono, Meity Ardiana, Ruddy Hartono

161. The Antibacterial Activity of Kersen Leaves (Muntingia Calabura) Extracts against
Aeromonas Hydrophilia; in Vitro Study .................................................................................................... 857
Onny Kurnia Sari, Wahyu Tjahjaningsih, Sudarno

162. Could the Severity of Infected Gingiva in Pregnant Woman Affect the Quality of Life? ......................... 862
R. Darmawan Setijanto, Novia Setyowati, Taufan Bramantoro, Achmad Aghasy

163. Age and Education Distribution Patterns of Working Mothers on Dental Health Behavior in
Preschool Children in Mid-Class Society ................................................................................................. 867
Isnawati, R. Darmawan Setijanto, Taufan Bramantoro, Dinda Dewi Zalinda

164. Relationship between Behavior and the Use of Personal Protective Equipment to Pesticide Consumer
Farmers in Tonrong Rijang Village Baranti District Sidenreng Rappang District .................................... 872
Zaenab, Ashari R, Nurmin

165. Hazard Identification, Risk Assessment, and Determining Controls in Laboratories ............................... 877
Ais Assana Athqiya, Dani Nasirul Haqi, Putri Ayuni Alayyannur, Indriati Paskarini, Fauziah Mukti Sugiharto

166. Risk Analysis of Accidents and Occupatioal Disease in Ohs (Occupational Health and Safety) Laboratory 884
Muhammad Yusuf, Dani Nasirul Haqi, Putri Ayuni Alayyannur, Endang Dwiyanti, Nur Laili R

167. Gluten-Free Diet: Positive and Negative Effect on Human Health ........................................................... 889
Botagoz Kulushtayeva, Maksim Rebezov, Aidyn Igenbayev, Yulia Kichko, Nina Burakovskaya, Vladimir
Kulakov, Mars Khayrullin
168. Comparing Lower Grades and Higher Grades Astrocytoma in Three Age Groups: by CD133 Antibody 893
Zainab Zahid Saadoon, Huda Mahdi Al-Khateeb, Khitam Abdul-Razak Alkhafaji

169. Differences in Growth of Children with Autism and Normal in Surabaya, Indonesia .............................. 899
Dewi Setyowati, Budi Prasetyo, Dominicus Husada

170. Functional Outcome after Conventional Open Discectomy for Patients with Herniated Lumber Disc:
One Year Follow Up .................................................................................................................................. 904
Mohammed Hassan Razoki

171. Early Complications Following Bipolar Hemiarthroplasty as Primary Treatment for Displaced
Femoral Neck Fracture in Elderly Patients ............................................................................................... 909
Mohammed Hassn Razoki, Adnan Essa Elkelaby

172. Assessment of the Anterior Talofibular Ligament(ATFL) Thickness in Chronic Stroke

Patients by Ultrasound .............................................................................................................................. 915
Mohammed Hassn Razoki, Nada Rida Alharis, Haider Kadhim Hussain

173. Classroom Control Patterns and its Relation to the five major Factors of the Personality of
Sports Education Teachers in Babil Governorate ...................................................................................... 921
Aied Kareem Abdaun, AbdulrhmanGhadhab AL-SAADI, Haedar Sami Mohammed

174. Effect of Speed Training Technique in Determining the Effectiveness of Creatine and
Phosphorus for Advanced Volleyball Players ............................................................................................ 926
Amal Sabeeh Salman Al-Tamimi

175. Study of the Effect of Different Intensity and Duration of LED Light on Shear Bond Strength and
Adhesive Remnant Index of Metal Orthodontic Brackets ........................................................................ 932
Zahraa M. Al-Fadhily, Sattar J. Abdul-Zahra Al Hmedat, Zuha Ayad Jaber

176. Comparative Study between Muscle-Split Versus the Classical Muscle-Cut Subcostal Incision for
Open Cholecystectomy .............................................................................................................................. 938
Awni Ismail Sultan, Khalid Khairi Hussein

177. Association of Idiopathic IUGR with Placental Histological Morphometry ............................................ 943
Mohammed E. Ghanem, Samia A. Eleiwe, Nagham K. Tayeh

178. Evaluation of Polycystic Ovarian Syndrome Women as a Result of Clomiphene Treatment ................... 949
Zainab Abdul wahed Naji

179. Variance Analysis of Acute Myocardial Infarction Clinical Pathway in The Era of National Health Insurance
954
Fadlia Fardhana, Kurnia Sari, Atik Nurwahyuni
180. Indoor Particulate Matter (PM10) and Health Risk on Junior High School Students in Depok ................ 960
Sasnila Pakpahan, Bambang Wispriyono

181. Analysis of Typhoid Fever Clinical Pathway Implementation in the Era of

National Health Insurance in Indonesia .................................................................................................... 965
Widia Puspa Hapsari, Atik Nurwahyuni

182. Analysis of Primary Health-Care Resource Preparedness for Implementation of Maternal

HIV Screening in Indonesia’s Urban Areas .............................................................................................. 971
MM.Puspitasari, Purnawan Junadi
13
13

183. Getting Married to a Suspected Bisexual Man: A Silent Mode of HIV transmission among
Married Women in Indonesia .................................................................................................................... 976
Najmah, Sharyn Graham Davies, Sari Andajani

184. mHealth Development for Village Midwives to Improve the Performance of the Maternal Health
Program in the Babakan Madang Sub-District, Bogor, Indonesia ............................................................ 981
Rico Kurniawan, Kemal N. Siregar, Nimas S. Martiana, Indriana K. Wardhani

185. The Influence of Dental Health Education on the Gingival Health of Students at STIKES
Muhammadiyah Palembang ...................................................................................................................... 987
Dientyah Nur Anggina, Resy Asmalia

186. A Smart Nutrition Management System and Nutrition Related Diseases in Humans .............................. 992
Kardokh H. Kaka Bra, Eko Supriyanto

187. Dominant Hypertension Factors of Adolescents in West Java, Indonesia ................................................ 997
Mujahidil Aslam, Trini Sudiarti, Ratu Ayu Dewi Sartika, Engkus Kusdinar Achmad

188. Discogenic Low Back Pain, Diagnostic Criteria ..................................................................................... 1003

Mahmoud Ramadan Adly, Ahmed Hossameldin Hussein, Omyma Sayed Mahmoud

189. Ultrasound Guided Enhanced Recovery Program in Colorectal Surgery: Kasralainy Modified Protocol 1009
Ahmed FA Farag, Hany MS Mikhail, Hamed H Elsheshiny, Moataz F Mohamed, Osama RM
Refaie, Haitham SE Omar, Ahmed MSM Marzouk

190. The Use of Intra-articular Steroid Injection to improve functional outcomes in Tibial Plateau Fractures 1014
Sherif Hamdy Mohamed Zawam, Ahmad Salah Muhammad Abu Taleb

191. Relationship between Hygiene and Sanitation with Coliform Bacteria Contamination in Refill Drinking Water
1019
Indah Ananda Jamaluddin, Agus Bintara Birawida, Ruslan

192. Relationship between Work Posture and Musculoskeletal Disorders (Msds) at Processing Workers in
PtToarco Jaya, Rantepao City year 2017 ................................................................................................. 1025
Januarty Triani Rimba, Furqaan Naiem, Muhammad Rum Rahim

193. A Study on Frequency of 12-23 Months of Children Visits to Integrated Service Post (Posyandu)
3 Months in a Row against Developments in the Work Areas, Makassar City ....................................... 1030
Khalis Muliamar, Djunaedi M. Dachlan, Burhanuddin Bahar

194. Analysis of Ability to Pay National Health Insurance Contributions to Communities on

Lakkang Island, Makassar City in 2017 .................................................................................................. 1035
Andi Sahriana, Dian Saputra Marzuki, Muhammad Yusri Abadi

195. Factors Associated with Musculoskeletal Disorders (MSDs) Complaint on the Workers of
Cargo Unit at PT. Angkasa Pura Logistics, Makassar in 2017 ................................................................ 1040
Firmita Dwiseli, Muhammad Rum Rahim, Awaluddin

196. Relationship between Heat Pressure and Age with Work Fatigue among Workers at Department
Factory I of Pt. Maruki International, Makassar in 2017 ........................................................................ 1045
Ulfa Rahman, Masyitha Muis, FurqaanNaiem

197. Relationship of Health Service Quality with Inpatients’ Loyalty at RSUD M akassar City ................... 1050
Sri Wahyuni, Nurhayani, H. Indar
198. Relationship of Marketing Mix with Loyalty of Patients of Dental Poly in BatuaPuskesmas,
Makassar City in Year 2016 .................................................................................................................... 1056
Suciana Aprilia Angraeni, Nurhayani, H. AmranRazak

199. Relationship of Marketing Mix with Return of Outpatients’ Interest at Dr.TadjuddinChalid

Specialist Hospital, Makassar in 2017 .................................................................................................... 1061
YustiamkaPermana, H. Indar, Nurhayani

200. The Factors Related to Work Fatigue of Block Paving Workers at CV. SumberGalian in 2017 ............ 1066
Putri Yanti, Andi Wahyuni, Awaluddin

201. Factors toward Diabetes Mellitus Type II Occurrence among Patients in Tenriawaru Hospital,
Bone Regency 2014 ................................................................................................................................. 1071
Jumriani Ansar, Indra Dwinata, Hardiana

202. Mapping of Dengue Fever Incidence in Majjene Province, West Sulawesi 2016 .................................. 1075
Jufri, Agus Bintara Birawida, Fajaruddin Natsir

203. Factors Contribute to KB Contraception Equipment Service in Reproductive Age Couples in

Tamalanrea Public Health Center ............................................................................................................ 1080
Karmiah, Muhammad Yusran Amir, Muh. Yusri Abadi

204. Factors toward Dengue Haemorrhagic Fever Occurrence in Patte’ne Village,

North Wara District, Palopo City ............................................................................................................ 1085
Sari Puspa Bachtiar, H.A. Arusnan Arsin, Dian Sidik Arsyad

205. Factors that Influence Patients in Utilizing Outpatient Services in Hasanuddin University Hospitals ... 1090
Alamsyah, Fridawathy Rivai, Rini Anggraeni

206. Relationship of Marketing Mixes with the Return Interest of Patients at ArifinNu’mang Hospital ....... 1095
Ardiyansah H. Lammade, Asiah Hamzah, Sukri Palutturi

207. Relationship Analysis between the Quality of Health Services and Patients Satisfaction in
Kapasa Health Center Makassar City ...................................................................................................... 1100
Fidelia Lolo Pirade, AmranRazak, Nurhayani

208. Factors Related to Complaints of Low Back Pain in Workers in Pt Maruki

International Indonesia Makassar City .................................................................................................... 1105
Ridha Astuty T, Syamsiar S. Russeng, Awaluddin

209. Relationship of Marketing Mixes and Utilization of Dental Poly in KassiKassi Health Center ............ 1110
Sitti Arabiyah Yunus, Darmawansyah, Nurhayani

210. Factors Related to the Fatigue in Workers in the Cargo Unit of Pt. AngkasaPura Logistic Makassar ... 1115
Syur Aulia Jufri, Andi Wahyuni, Muhammad Rum Rahim

211. Relationship of Climate Factors with Diarrhea Evaluation in City of Makassar .................................... 1120
Tri Hastuti Handayani, Anwar Daud, Makmur Selomo

212. Analysis of Health Service Quality on Patient Satisfaction in Malimongan .......................................... 1125
Putri Lisyah Tome, Nurhayani, Darmawansyah

213. Work Fatigue Overview in Female Workers in PT Manakarra Unggul Lestari ...................................... 1130
Gracella, Awaluddin, Andi Wahyuni
214. Factors Related to the Satisfaction of Patients in Pelamonia Hospital .................................................... 1135
Andi Nahlah, Sukri Palutturi, Muh. Yusri Abadi

215. Risk Factors of Pulmonary Tuberculosis Relapse in Working Population of Makassar City ................. 1140
Irmawati, Ridwan A, Jumriani Ansar

216. Health Belief Model and Its Association with Cervical Cancer Screening Among Malaysian Women . 1145
Fadzilah Siraj, Md Radzijohari, Nur Azzah Abu Bakar, Faizzudin Sahazudin

217. Level of Spirituality and Demographic Factors among People Living with HIV/AIDS ........................ 1152
Rajwani Md. Zain, Zarina Mat Saad, Fatimah Zailly Ahmad Ramli

218. Description on the Quality of Life among Elderly Affected by Dental and Oral Health in
Jagir Health Centre Surabaya .................................................................................................................. 1159
Rima Arsyilviasari, Tiara Meilena, Ayu Setyowati, Retta Gabriella Pakpahan, Nur Latifah
Zuniati, Alvita Wibowo, Darmawan Setijanto

219. Genetic Diversity of Anopheles sp as Malaria Vectors Who Carries Plasmodium Falciparum and
Plasmodiumvivax Which Can Infect Human in Jayapura Municipal, Papua Province, Indonesia ......... 1163
Yohana Sorontou, Henny Sesanti Budi Hastuty

220. The Use of Portable WSD Wound Models to Improve Student Clinical Lab Skills ............................... 1169
Pramita Iriana, Ratna Sitorus, Agung Waluyo, Sutanto Priyo Hastono

221. The Role of SOD, Catalase, HSP-27, HSP-70, and TNF-α Expression in Apoptosis of
Retinal Ganglion Cells After Intra Ocular Pressure Increase on Rattus Norvegicus .............................. 1174
Nurwasis, Gatut Suhendro, I Ketut Sudiana

222. The Relationship Between Nurse Caring Behavior and Patient Satisfaction Level at
Inpatient Wards of Bayangkara Hospital Jayapura ................................................................................. 1179
Jems K. R. Maay, Ester Rumaseb, Arwam Hermanus

223. Job Satisfaction and Mental Health among Bank Employees of Chidambaram Town ........................... 1184
N. Madhavan

224. Neurodevelopmental Screening—A guide for Early Intervention in at-Riskinfants .............................. 1188
N. Meena

225. Local Wisdom in Pregnancy, Childbirth, Childcare in Mee Tribe, Papua .............................................. 1193
Heni Voni Rerey, Cristina Tien Popang, Butet Agustarika, Ester Rumaseb

226. Implementation of Fixed Procedures for Care Action of Archipelago Surgery in the
Regional General Hospital of Doc II Jayapura ....................................................................................... 1198
Demianus Tafor, Jems K. R. Maay, Arwam Hermanus, Ester Rumaseb

227. The Affairs of Anopheles Mosquito in the Working Area 2015 Hamadi Puskesmas Kota Jayapura ...... 1203
Marlin Mayling Jarona, Henny Sesanti Budi Hastuty, Muhammad Abas, Arwam Hermanus

228. Intervention Effect of Ultra Violet and Exhause Lights on Microbal Density Decreasing in
Honai in Kurulu District, Jayawijaya District, Papua Province .............................................................. 1208
Frans Manangsang, Ester Rumaseb, Abdul Ganing, Suningsih Suabey, Arwam Hermanus, Jems KR Maay

229. A Model of Malaria in Pregnancy Prevention Counseling in Clinics District of Jayapura, Papua ......... 1213
Ester Rumaseb, Hari Kusnanto, Djaswadi Dasuki, Siswanto A Wilopo, Jems KR Maay, Arwam Hermanus
230. Molecular Docking Studies of a Chalcone Derivative Compound p-hydroxy-m-methoxychalcone with
Tyrosine Kinase Receptors ......................................................................................................................1219
Retno Arianingrum, Adam Hermawan, Hari Purnomo, Dyaningtyas Dewi, Edy Meiyanto

231. Clean Healthy Living Behaviours (Phbs) Household Order Kampong Sarmi Regency
Bonggo Subdistrict Armopa Papua in 2017 ............................................................................................ 1225
Arwam Hermanus MZ, Ester Rumaseb, Renold M Mofu, Jems KR Maay, DemianusTafor, Zeth Robert
Felle, FrengkiApay

232. Global Trend on Incivility Research ....................................................................................................... 1229

Nurul Ain Hidayah Abas, Aidi Ahmi, Mei-Hua Lin, Asma Perveen

233. A New Approach to Detect Macular Hole from Optical Coherence Tomography Images ..................... 1235
M. Anand, C. Jayakumari

234. Synthesis and Characterization of Graphene Quantum Dots from Turmeric Powder (Berberisaristata)
and Its Biomedical Applications .............................................................................................................. 1239
Anooj E. S., V. Suganthi, P. K. Praseetha

235. Development of Novel Classifying System to Identify the Right Sense of Image Sharing in
Social Networks Using Deep Convolution Neural Network ................................................................... 1244
P. Nirupama, E. Madhusudhana Reddy

236. Identification and Molecular Phylogenetic Relationship of Selected Medicinal Plants-Ethano

Medicinal Importance .............................................................................................................................. 1248
Lekshmi Gangadhar, P. K Praseetha

237. Accuracy of Out of Field Photon Dose Calculations by a Treatment Planning System ......................... 1253
Silpa AjayKumar, MM Musthafa, JayaPrasad Tripathy, Karthickeyan Duraisamy, Resmi K
Bharathan, Suja Cheruliyil Ayyappan, Geetha Muttath

238. Evaluating the Biological Potential of Phyto-compounds from Myristica fragrans Seeds .................... 1260
Vibala B. V., P. K. Praseetha

239. Evaluating the Biological Applications of Myristica fragrans Seeds for Bactericidal and Cytotoxic Effects 1267
Vibala B. V., V. Suganthi, P. K. Praseetha

240. Elevated Anticardiolipin Titer as a Stroke Factor in Young Patients in Kirkuk City .............................. 1273
Raad Hassan Najim, Bilal Jamal kamal

241. ODAP: The Natural Toxin Present in The Lathyrus Sativus (Grass Pea) ............................................... 1277
Durar Kamil Jabbar, Habeeb Kadhum

242. Safety Disposal of Electrophoresis Gels and PCR Contaminate with Ethidium Bromide and
Alternative Methods ................................................................................................................................ 1283
Amal Raqib Shamran, Methaq Hadi lafta

243. Enhancement in Segmentation of Brain Tumors on MRI Using Region Growing Algorithm ............... 1286
K. V. Shiny, N. Sugitha, B. Swaminathan, B. Bhuvaneswaran

244. Design of a Prototype System to Determine Ammonia Concentration in Exhaled Human

Breath in the Diagnosis of Kidney Failure .............................................................................................. 1292
Nihitha Rajendran, P Vinupritha, D Kathirvelu
245. Enhancing Blood Cell Images using Denoising Filters for the Detection of Hematological Disorders 1297
Aldrin Karunharan K, Om Prakash

246. Development of Gas Sensor Device for Primary Health Care Monitoring System ................................ 1303
Shifa Anas, Gnanavel S.

247. A Descriptive Study on Mental Stress, Time-Management & Worklife-balance among Ph.D. Scholars 1308
Aalim P. N., Ambily R

248. Image Segmentation for Diabetic Retinopathy Using Modified Bacterial Foraging Optimization Algorithm 1313
Hema Rajini N

249. Segmentation of Human Eye Pupil with Novel Grid Based Localization Computing ........................... 1320
G. Sumathy, J. Arokiya Renjith

250. Cardiac Tele-care ..................................................................................................................................... 1326

D. Pavithra, P. Raja Rajeswari Chandni, D. Padmini, S. Vishnu Priya, R. Vanithamani

251. A Map Reduce Framework for Identifying Association Rules between Clinical Traits of Asthma ........ 1329
S. Poorani, P. Balasubramanie

252. A Study on Knowledge, Attitude and Practices towards Breast Cancer among Reproductive
Age Group Women in an Urban Area of Coimbatore ............................................................................. 1332
Jasmine J Nirmal, Prabhu N J, Sugunadevi G

253. Health Promoting Lifestyle Practices: A Comparative Study on Health and

Non-Health Professional Students ........................................................................................................... 1337
Bitty Joys, Sonamtsomu G, Dekey Yanzom

254. Effectiveness of Stress Management Strategies on Occupational Stress in Educational Institution ....... 1343
Jasmine Joseph, C. Lalroluahpuii, Chime Dolkar, Yojna Chettri

255. Effectiveness of Station-based Skill Training Model through Objective Structured Clinical
Examination (OSCE): Nursing Students’ Skills in Performing the Clinical Procedures ........................ 1349
Rinu Mathew, Sujata Regmi, Bombo Ekane Dorothee V

256. Cogency of Aggression Management Training Programme on Competency of Nursing

Students in a Selected College in Bangalore ........................................................................................... 1355
Meenu Cherian, Jenila J, Swetha Sharma

257. To Assess the Knowledge and Attitude Towards the Prevention of Traffic Collisions among College Students
1361
Sowbagya Lakshmi A, Komal Sharma, Monica

258. Classification of Retinal Disorders Based on Fluid Patterns in OCT Images ......................................... 1367
Venkatraman K., M. Sumathi

259. Analysis of Skin Cancer using K-Means Clustering and Hybrid Classification Model ......................... 1371
Bethanney Janney J, S.Emalda Roslin

260. Application of Harmony Search Algorithm in Retinal Biometric System .............................................. 1379
J. Sivakamasundari, A. Devi Lakshmi, P. Madhumitha, Pallabi Ghosh

261. Application of Clustering Techniques on Statistical Features of EEG Signals for Seizure Detection .... 1384
P. Grace Kanmani Prince, J. Premalatha, D. Marshiana, Krishnamoorthy Raghavan, Suresh Kumar
18 18

262. Face and Finger Vein Recognition for Security Based Electronic Voting Machine Using Raspberry Pi 1390
T. Thaj Mary Delsy, G. Rajalakshmi, D. Jamuna Rani, V. Amala Rani, S. Sidharthan, Praveen K. Pradeep

263. Health Parameter Analyses of Living Organism in Underwater Environment ....................................... 1394
T. Thaj Mary Delsy, D. Jamuna Rani, D. Marshiana

264. Recent Medical Image Fusion Techniques: A Review ............................................................................ 1399

V. Amala Rani, S. Lalithakumari

265. A Literature Study on Detecting Gall Bladder’s Wall Thickness for Finding Early
Abnormalities using Ultrasonic Images .................................................................................................. 1404
G R Jothilakshmi, Rubina R, V Rajendran, Y Sreenivasa Varma

266. Skin Reflectance Based Diagnosis and Monitoring of Thyroid Diseases ............................................... 1408
J.Sofia Bobby, Ralan Barathi E, Srinithi V, Salome G, Jayasurya A

267. Wound Healing Properties and Cytotoxicity of Gold Nanoparticles on MDCK Cell Lines (in Vitro Study) 1412
Najwa Kahtan Aljbory, Nissren Jalal Mohammed, Rana A. Ghaleb

268. Spinal Anesthesia for Knee Arthroscopy without Fluid Preloading ........................................................ 1418
Isra Hamed Saeed

269. Femoral Nerve Block and Adductor Canal Block for Postoperative Analgesia of
Total Knee Replacement, Comparative Study ........................................................................................ 1421
Isra Hamed Saeed, Mohammed Asi Jabbar

270. The Serum Micro RNA-375 Utility to Diagnosis of Men with Prostate Cancer in Iraq ......................... 1425
Kadhum J. Mowayeiz, Najat Abudlrazzaq Hasan, Alaa G. Hussein, Estabraq AR. Al-Wasiti, Usama
S. Al-Nasiri

271. Anticardiolipin Antibodies in Comparison to B-HCG Titer and Serum Progesterone as

Indicator for Ectopic Pregnancies ........................................................................................................... 1431
Wasan Wajdi Ibrahim
Indian Journal of Public Health
Research & Development

www.ijphrd.com
CONTENTS
Volume 10, Number 7 July 2019

272. Knowledge Regarding Risk Factors of Hypertension among Young Adult Students ............................ 1436
Sanjivani Maral, Muskan Marwah, Sahil Vijaykumar Lahoti, Arindam Das

273. Incidence of Anxiety among First Year College Going Students ........................................................... 1442
Diana Prasad

274. A Study to Assess the Effectiveness of Structured Teaching Programme on Knowledge Regarding
Substance Abuse and Its Impact on Health among Higher Secondary Students among Atulya Healthcare,
Pune ........................................................................................................................................................ 1446
Tejashri Ligade, Sagar Kulkarni, Aejaz Ahmad

275. Awareness and Assessment of Level of Disaster Preparedness among Nurses of Hospitals ................. 1451
Jasneet Kaur, Sheela Upendra, A. Seeta Devi, Sheetal Barde, Sheetal Waghmare

276. Integrating High Fidelity Simulation with Patient Assessment Using International Trauma Life Support
(ITLS) Protocols for Prehospital Scenarios amongst Emergency Medical Services (EMS) Students of
Pune, India............................................................................................................................................... 1454
Parag Rishipathak, Shrimathy Vijayraghavan, Anand Hinduja

277. Assessment on the ‘Impact of Nutrition Exhibition ‘on Knowledge level among Rural Women in Selected
area of Pune District ............................................................................................................................... 1458
Sheela Upendra, Jasneet Kaur, Seeta Devi, Sheetal Barde, Shitalwaghmare

278. A Study to Assess the Effectiveness of Structural Teaching Program on Knowledge and Attitude of Nurses
Regarding Fecal Microbial Therapy (FMT) in Selected Hospitals of Pune City.................................... 1462
Deepak Sethi, Shobha Naidu, Maj Kirti

279. Knowledge regarding Total Parenteral Nutrition (TPN) among the ICU Nurses in Selected Hospital of
Pune City.................................................................................................................................................. 1467
Manisha Vikrant Mistry

280. Awareness of Students Regarding the Effect of Mobile Phone Usage on Health at an Indian
University................................................................................................................................................. 1472
Milind Chukhare, Sammita Jadhav

281. A Study to Assess the Effectiveness of Structured Teaching Programme on Bio-waste Management with
reference to Knowledge among Nurses................................................................................................... 1478
Ranjana Chavan, Sheela Upendra

282. Effect of Flipped Classroom Teaching on Improvement of Clinical Performance in Labour Room among
Nursing Students .................................................................................................................................... 1481
Seeta Devi, Sheela Upendra, Jasneet Kaur, Shitalwaghmare, Sheetal Barde
283. Development of Norms for Cardiovascular Endurance Test for Youth Aged 18 – 25 Years...................1486
Amritashish Bagchi, Nayana Nimkar, Rajiv Yeravdekar

284. Analysis of Pesticide Content in Selected Onion Samples by Chromatography and Mass
Spectrometry............................................................................................................................................ 1492
Ankita Kulkarni, Vaishnavi Soman, Avril Jacques, Pratima Jasti, Selvan Ravindran

285. Effects of Dance (Bharatanatyam) on the Body Composition, Nutritional Status, Fitness and Mental
Abilities of Children and Adults– A Narrative Review .......................................................................... 1497
Apoorva Rao, Sneha Majumder, Kavitha Menon

286. Prevalence and Determinants of Vitamin-D Status in Subjects with Type II Diabetes
Mellitus.................................................................................................................................................... 1503
Arti Muley, Uma Iyer

287. Management of Complete Placenta Previa – A Case Study.....................................................................1509

Deepa Patil, Manisha Vikrant Mistry

288. Effect of Educational Intervention on Menstrual Hygiene on Knowledge, Perception and Practices of
Adolescence Girls.....................................................................................................................................1513
Dipali Dumbre, Seeta Devi

289. A Study on Prevalence of Metabolic Syndrome (M.S.) and Associated Risk Factors among Rural Women
at Rural Block of Pune District................................................................................................................ 1516
S G. Joshi, Mangesh V. Jabade, Shital V Waghmare, Ranjana Chavan

290. Study on Acute Respiratory Diseases among Children of below Five Years in India ............................ 1522
Rohit Singh Tomar, Parag Rishipathak

291. The Effectiveness of use of Electronic Medical Record System at University Health Centre .............. 1526
Alaka Chandak, Rajesh Shinde

292. Hypertension and its Association with Low HDL and High LDL in Cardiovascular Disorders ........... 1532
Jenu Maria Thomas, Sammita Jadhav

293. Perception of Healthcare Education Ecosystem among International Students Pursuing Medical
Technology Specialisation in Western India.............................................................................................1638

294. Impact of Dietary Interventions on Anxiety, Depression and Stress – A Narrative Review .................. 1544
Gayatri Shanbhag, Pooja Panchal, Kavitha Menon

295. An Exploratory Pilot on Body Composition and Nutrient Intake Associated With Premenstrual Syndrome
among Young
Women...............................................................................................................................1551
Harshada Thakur, Priyanka Pareek, Suhas Otiv

296. Pocrescophobia: It’s Influence on Eating Habits..................................................................................... 1557

Leeja Bonny Thomas, Shital Barde

297. A Study to Assess the Effectiveness of Self-Instructional Module on Knowledge and Practices of Needle
Stick Injury among the Nurses Working in Selected Hospitals of Pune City.......................................... 1562
Mangesh V. Jabade, S G. Joshi, Ranjana Chavan

298. Understanding Reasons for Rise in Conflict Situation in an Indian Hospital and Suggesting Measures to
Minimize Them .......................................................................................................................................1566
Meenal Kulkarni
299. Back Stretch Exercise Vs Pelvic Tilt on the Backache among Antenatal Mothers................................ 1571
Pallavi Shinde, Merlin Suji

300. Effectiveness of Demonstration on Neonatal Resuscitation Practices among the Nurses........................1577

Manu Acha Roy

301. Serving Vegan Palates Nutritiously: Fortification of Vegan Cake with Garden Cress Seeds and Rose Petal
Preserve as Functional Ingredients...........................................................................................................1582
Neelam Giraje, Radhika Hedaoo

302. Assessment of Patient Safety Culture in a Tertiary Care Hospital In Pune.............................................1588

Neha Ahire, Kurapatti Ambika Shrinivas

303. Intelligence Quotient and Nutritional Status of 4-6 Year Old Children from Fishermen Community of Goa,
India..........................................................................................................................................................1594
Neha Sathe, Devaki Gokhale

304. A Review of the Nutritional Quality of School Canteen Foods in South Asia.........................................1600
Purva Sharma, Surabhi Singh Yadav, Kavitha Menon

305. A Study to Assess the Social Functioning Level of Alcohol Dependents in Selected Rehabilitation
Centre........................................................................................................................................................1607
Roma Sunil Shinde, Sheela Upendra

306. Perspectives of Service Users While Choosing a Clinical Laboratory for Testing .................................1611
Sanjivani Maral, Suvarna Joshi, Ashish Banerji3, Snehal Kale

307. Time Line Practice of Yoga on the Level of Depression .........................................................................1617

Sharadha Ramesh

308. Effectiveness of Music Therapy on Anxiety among Elderly Residing at Selected Geriatric Homes at Pune
City............................................................................................................................................................1621
Sheetal Barde, Sheela Upendra, Kalpana Sawane, Shital Waghmare, Seeta Devi

309. A Comparative Electromyographical Investigation of Latissimus Dorsi and Biceps Brachii Using Various
Hand Positions in Pull Ups.......................................................................................................................1624
Shiny Raizada, Amritashish Bagchi

310. A Protocol for Improving Nursing Performance Towards Placental Examination among Staff Nurses at the
Labor Room in Selected Hospitals of Pune City......................................................................................1630
Shital V Waghmare, Sheela Upendra, Seeta Devi A, Jasneet Kaur, Sheetal Barde, S.G Joshi

311. Low Doses Ionizing Radiations: A Risk for Cancer and Cardiovascular Diseases..................................1634
Yogita Dhas, Neetu Mishra

312. Molecular Epidemiology of Japanese Encephalitis Virus in India............................................................1640

Azima Khan, Sammita Jadhav

313. Neglected Bacterial Foodborne Pathogens in India..................................................................................1645

Azima Khan, Sammita Jadhav

314. Utility of High Fidelity Simulation Training in Improving Adherence to Critical Actions During
Cardiopulmonary Arrest...........................................................................................................................1650
Parag Rishipathak, Monesh Bhandari, Anand Hinduja
315. Clinical Diagnostic Marker for Early Detection of Epithelial Ovarian Cancer: Classical biomarkers and
MicroRNAs...............................................................................................................................................1654
Joyita Banerjee, Neetu Mishra

316. Assess the Knowledge Regarding Prevention of Dental Carries Among Schoolchildern...................... 1662
Priyanka Kadam, Mangesh V. Jabade, Ranjana Chavan
DOI Number: 10.5958/0976-5506.2019.01527.4

Effect of Therapeutic Exercises on Pre-Menopausal Symptoms

in Sedentary Life Style Women

Aishwarya V. Ahiwale1, S. Anandh2, Pranjali Gosavi3

1
MPT, 2Professor, 3Assistant Professor, Department of Community Health Science, Krishna College
of
Physiotherapy, KIMS ‘Deemed to be’ university, Karad, Maharashtra, India

ABSTRACT
Objectives: The purpose of this study was to check the effect of therapeutic exercises on pre- menopausal
symptoms in sedentary life style women.
Method: 65 subjects were included who were having pre- menopausal symptoms with age group between
35-55 years were included in study. These subjects were allocated by simple random technique. During Pre
-treatment and post treatment assessment severity of pre- menopausal symptoms assessed by
menopausal
rating scale and quality of life assessed by SF- 36 questionnaire. These outcome measures were analyzed.
Result: Pre and post treatment protocol was analyzed by using ANOVA test. Data analysis showed
extremely
significance in menopausal rating scale (p=0.0001) and SF-36 (p=0.0001).
Conclusion: The effect of therapeutic exercise protocol has shown significant improvement in pre-
menopausal sedentary life style women with the help of menopausal rating scale and SF-36 questionnaire.

Keywords: Pre–menopausal symptoms, sedentary life style women, therapeutic exercises.

Introduction Email: [email protected]

Menopause: Menopause is defined as a time of

cessation
of ovarian function resulting in permanent amenorrhea.1
2
menopause commonly occurs above the age of 40
years.2,3 In India 60 millions of women are above the
age of 40 years.2 Many of them menstruate well beyond
the age of 50 also.1 If the Menopause occurs before the
age of 40 then it is known as premature menopause.1
Menopause age not depend upon her menarche, number
of pregnancies and lactation or taking oral
contraceptives and socio-economic status It may depend
upon her nutritional, environmental as well as on genetic
factors.4,5

Corresponding Author :
Aiahwarya Vijay Ahiwale,
MPT, Faculty of Physiotherapy,
Krishna Institute of Medical Sciences
Deemed to be university,
Karad 415110, Maharashtra, India
Phone: 8600533008
Pre–menopause and its symptoms: The phase of
Pre-menopause is of 3-4 years before menopause. 1,3 In
this period almost 60-70% women go through various
pre-menopausal physiological changes such as gradual
decrease in the amount of blood loss with each period,
gradual increase in the spacing of periods. The most
common and noticeable symptoms are hot flushes and
sweating which are the main symptom of the climacteric
period in 85% women. Hot flushes are commonly seen
on face and neck region and these last for 2-5 min
each. Headache and severe sweating, disturbed sleep,
Palpitation and angina pains may be additional features.
In some women mental depression, irritability, and lack
of concentration are noticed. Neurological, vasomotor
symptoms and paraesthesia take the form of sensation
of pins and needles in the extremities. With regard to
Urinary tract - deficiency of oestrogen leads to urethral
caruncles, dysuria with or without infection, urge and
stress incontinence. Genital-Atrophic vagina reduces the
vaginal secretion, and dry vagina can cause dyspareunia.
Imbalance of Libido (sexual feeling) may increase in
some women but in some women it is decreased. 1, 6,7,8,9.
2 Indian Journal of Public Health Research & Development,
Indian Journal of PublicJuly 2019,
Health Vol.10, &
Research No. 7
Development, July 2019, Vol.10, No. 7 2

Physiology of exercise: Exercises help to maintain day. The procedure of therapeutic exercise protocol
physical fitness. The physiological effect of exercise which includes with warm up exercises, stretching,
is depends on intensity, duration and frequency as strengthening exercises, aerobic exercises, relaxation
well as environmental factors. During exercise there is technique and cool down exercises are advised and made
increased demand of circulatory systems to meet this to be performed by the subjects under the supervision
need of oxygen and nutrients improving metabolism as per the protocol. Consecutive outcome measures was
with removal of carbon dioxide. Due to these demands done every month to know the progress for a period of
chemical, mechanical, and thermal stimuli affect four months. Pre and consecutive post- test measures
alterations in metabolic, cardiovascular and ventilatory was recorded for statistical analysis.
functions. A recent study on Exercise training has shown
Exercise protocol:
significant results with regard to the self - reported
frequency and severity of hot flushes.10 1. Warm-up: Low intensity free exercises for upper
limb, lower limb and trunk for 8-10 minutes.
Thus, it is essential to study effect of therapeutic
2. Stretching exercises: Self –stretching was given
exercises on pre – menopausal symptoms in sedentary
after instruction and supervision for 30 sec hold
life style women. Also there is a need of study to find
and 3 repetition for each.11
out the effect of therapeutic exercise programme on pre–
menopausal symptoms as well as to promote women Upper limb: Bicep stretch, Triceps stretch,
with sedentary life style towards adherence to physical
Lower limb: Quadriceps stretch, Hamstring
exercises and its effects on health status during their pre–
stretch, Hip flexor stretch, Gluteus stretch, Hip
menopausal period.
adductor stretch, Calf stretch.
Neck muscle: Trapezius stretch.
Method
3. Strengthening exercises: Strengthening exercise
Population: The subjects which willing to participate in was given with resistance band for upper limb
the study was taken. The criteria for inclusion were: and lower limb flexors, extensors, adductors,
Age:
abductors for 3 sets and 3 repetition for each.11
35 to 55 years with pre-menopausal symptoms, non-
exercising women excluding daily routine house hold 4. Aerobic training: Brisk walk was given to the
work. Exclusion criteria: Subject associated problem subjects for 15 minutes.11
with gynecological conditions such as - Uterine fibroids, 5. Relaxation technique: Jacobson relaxation
Carcinoma, Uterine cyst, Subject undergone with any technique- Instruct subject to contract any group
surgery in past 6 months and any disabled female. or series of muscles as strongly as possible and
then tell to let go and continue to let go.12
65 pre- menopausal sedentary life style women
were selected from Krad. And written consent form was 6. Cool down: Cool down period includes with low
taken. All the subjects were informed about the protocol intensity free exercises for 5 - 8 minutes.
and gave written consent before their participation. The
protocol and the consent form were previously approved This exercise programme was given for 4 days per
by protocol and ethical committee. week for 16 weeks.

Interventions: In this study total 65 subjects were Measurement Procedure:

included who were having pre- menopausal symptoms Menopausal rating scale (MRS): The MRS scale
which was confirmed by gynaecology department and contains 11 items, with a scores from 0 (none) to 4
those subjects satisfying inclusion criteria with age (extremely severe). Each subject was asked to mark the
group between 35-55 years were included in study. The box according to severity of their symptoms. The total
nature of study and interventions was explained to the score of the MRS ranged between 0 (asymptomatic) and
subjects and those who were willing to participate were 44 (highest degree of complain).The minimal/maximal
included in the study. Before proceeding to intervention, scores vary between the three dimensions of depending
a written consent was taken from individual participant. on the number of complaints allocated to the respective
Pre-treatment outcome measures of menopausal rating dimension of symptoms.
scale and SF-36 questionnaire will be recorded on
first
Quality of life (SF – 36): SF-36 which is a self- reported among sedentary life style women has been found
questionnaire consisting of 36 items but in that only 2 significant
domains are taken in this study which includes physical with p value <0.0001 which is statistically significant.
role and functions. Each subject was asked to mark the
box according to severity of their problems and the Statistical analysis: The data was entered into
domains are scored separately, and accordingly total score Microsoft office excels 2007 and analyzed using instat
is provided. software. Descriptive statistics were used to analyze for
demographic data: Pre and post treatment protocol was
analyzed by using ANOVA test and p value <0.0001
Result
was considered to be statistically significant.
Women with sedentary life style having pre -
As per the inclusion criteria 65 subjects were
menopausal symptoms and who have undergone a
included in the study. During 16 weeks of protocol which
therapeutic exercise protocol showed significant
includes with warm up exercises, stretching,
decrease in the severity of pre- menopausal symptoms,
strengthening exercises, aerobic exercises, relaxation
with p value was <0.0001 which is statistically
technique and cool down exercises was given and Pre
significant.
and post analysis was done for 65 subjects. In Table.1 and
In addition, Post intervention results of quality of life Table. 2

Table 1: Comparison of mean Pre- treatment and post treatment MRS score
Sr. No. Duration Mean SD Median F value p value Significance
1. Pre- day 1 31.69 5.33 31
2. Post- 4 week 31.41 5.33 31
Extremely
3. Post- 8 week 30.72 5.28 31 213.5 <0.0001
significant.
4. Post-12 week 29.93 5.35 30
5. Post- 16 week 29.07 5.26 30

The above table shows comparison of mean values and standard deviation of menopausal rating scores. The
values were compared by applying Friedman test. The pre and post treatment values shows that there was extremely
significant difference in menopausal rating score after 8 weeks. (p = <0.0001.)

Table 2: Comparison of mean pre-treatment and post-treatment SF-36 score

Sr. No. Duration Mean SD Median P value F value Significance
1. Pre- day 1 49.62 11.72 50.00
2. Post- 4 week 49.89 11.68 50.00
Extremely
3. Post- 8 week 51.10 11.69 50.00 <0.0001 91.794
significant.
4. Post- 12 week 54.17 11.95 53.57
5. Post- 16 week 56.25 12.06 53.57
The above table shows comparison of mean values responses on endocrinal and reproductive systems and
and standard deviation of SF- 36 (Quality of life). they influence the women’s quality of life. To overcome
The values were compared by applying tukey Kramer this problem a therapeutic exercise protocol was
multiple comparison test. Pre and post treatment values designed to the subjects with reference to their Pre -
shows that there was extremely significant difference in menopausal risk factors.13
SF- 36 after 12 weeks. (p = <0.001).
This research was conducted with the aim to
Discussion study the effectiveness of therapeutic exercises on pre-
menopausal symptoms in sedentary life style
Pre-menopausal women suffer with many health women.
issues due to various hormonal changes/physiological 65 participants with the age group of 35-55 years
participated in the study. The conclusion was drawn
by the outcome measures which showed significant After giving therapeutic exercise protocol there was
improvement in their pre- menopausal symptoms and in significant improvement in both MRS and SF-36. (Pre
quality of life. intervention scores: Mean of MRS - 31.69 and SF-36 -
49.62 & Post intervention scores: Mean of MRS - 29.07
Outcome measures were taken pre and post
and SF-36 - 56.25).
interventions of therapeutic exercise program in pre -
menopausal sedentary life style women. The following The results showed that there is significant
are the outcome measures which were used in this study. improvement in menopausal symptoms and quality of
z Menopausal rating scale (MRS). life post intervention of therapeutic exercise protocol
among females with sedentary life style undergoing the
z SF-36 questionnaire. climacteric period towards menopause.
The menopausal rating scale is consist with 11 The result of one study reinforce that short term
questions scale which was categorized from none to exercise approach is effective on menopausal symptoms,
extremely severe score. The correlation of coefficient of psychological health, and quality of life in post -
the sum score was r = 0.82. menopausal women. (Aysegil agil et al., 2010).14
In menopausal rating scale, symptoms such as heart
Related studies showed that exercise training
discomfort, sexual problems, bladder problems and
helps to reduce the acute physiological severity post-
dryness of vagina there was no significant changes seen.
menopausal hot flushes with 16 week exercise protocol
But in other symptoms such as hot flushes, sweating,
(Tom G. Baily, et al, 2015).10
sleep problems, depressive mood, irritability, anxiety
and musculo - skeletal discomfort there was significant Effectiveness of a modified version of the applied
improvement recorded. relaxation technique in treatment 0f premenopausal and
postmenopausal symptoms which depicts that 12 week
The second outcome measure is SF-36 which is
exercise programme of relaxation techniques help to
a self- reported questionnaire consisting of 36 items
reduce severity of pre-menopausal and postmenopausal
out of which 2 domains were considered in the study
symptoms. (Saensak et al 2013).15
which includes physical role and functions. The domains
are scored separately and accordingly total score is The study on Effects of Aerobic Exercise on
provided. The overall Cranach’s α coefficient of the SF- Estrogen Metabolism in Healthy Premenopausal
36 questionnaire was 0.791. Women has proved that exercise intervention resulted
The physical activity component of SF-36 is in a significant increase in the 2-OHE1/16αOHE1 ratio,
categorized according to intensity of exercises i.e., but no differences in other estrogen metabolites or ratios.
vigorous activities, moderate activities and daily (Alma J. Smith1, William R. Phipps2 2013 May.)16
activities. The results have shown no significant changes The impact of exercise protocol was positive among
recorded in vigorous activities but there was significant all the participants in the study. Hence the therapeutic
changes recorded in moderate and daily living activities.
exercise protocol was effective to decrease the pre-
The pre and post data was analyzed statistically menopausal symptoms as per their severity status
using Friedman test and tukey krammer multiple thereby improving quality of life too.
comparison test. The pre and post intervention values of
menopausal rating scale of the group compared by Conclusion
applying Friedman test. The results have shown
The study concludes that subjects doing regular
significant difference in post treatment values (p value
prescribed therapeutic exercise protocol had significant
<0.0001).
improvement clinically and shown statistically
The pre and post intervention values of SF-36 significant results in sedentary life style women with
questionnaire of the group compared by applying tukey decrease in severity of pre-menopausal symptoms
krammer multiple comparison test. The results have according to menopausal rating scale and improvement
shown significant difference in post treatment values (p in functional status according to SF- 36(Quality of life).
value <0.0001).
Hence the alternate hypothesis was accepted. 9. Juan Enrique M Blumel, relationship between
psychological complaints and vasomotor
Conflicts of Interest: There were no conflicts of interest
symptoms during climacteric, maturities 49
in this study.
(3),
Source of Funding: This study was funded by Krishna 2004.
Institute of Medical sciences Deemed to Be University, 10. Tom G. Bailey1 (et. al), Exercise training
Karad. reduces the acute physiological severity of post-
menopausal hot flushes, J Physiological 594.3
REFERENCES (2016) pp 657–667.
1. Howkins and bourne shows textbook of 11. Carolyn Kisner, Lynn Allen Colby. Therapeutic
gynaecology 2011. exercises 2007 by FA Davis Company.
2. Maninder Ahuja, age of menopause and 12. M. Deena Gardiner, fourth edition, the principles
determinants of menopause age: A PAN India of exercise therapy.
survey by IMS, journal of Mid - Life health.
13. ACSM, guidelines for exercise testing and
3. R. Sapsford, Women’s Health A textbook for prescription, American college of sports
physiotherapists (1997). medicine; senior editor Linda S (2011).
4. Saseendran Pallikadavath (et. Al.), Natural 14. Aysegil Agil (et al), short term exercise
menopause among women below 50 years in approaches on menopausal symptoms,
India: A- population – based study, the Indian psychological health, and quality of life in post-
journal of Medical research. menopausal women. Received 23 March 2010;
accepted 13 July 2010.
5. Torgerson DJ, (et. Al.), Factors associate with
onset of menopause in women aged with 45 – 49, 15. Asuprawita Saensak1 (et. al), Article was
Maturities. 1994; 19:83 – 92. published in international journal of women
health, Effectiveness of a modified version of the
6. Christan Nordqvist, Everyting you need to
know applied relaxation technique in treatment of pre-
about menopause, 2017. menopausal and postmenopausal symptoms. 4
November 2013.
7. Nanette Santoro, menopausal symptoms and their
management. 16. Alma J. Smith1 (et. al), The Effects of Aerobic
Exercise on Oestrogen Metabolism in Healthy
8. Deborah Grady, management of menopausal Premenopausal Women, Cancer Epidemiological
symptoms, the New England journal of medicine, Biomarkers 2013 May.
2006.
DOI Number: 10.5958/0976-5506.2019.01528.6

Does Commercially Available Tooth Brushes in India follow

Recommended American Dental Association (ADA) Norms?

V. Anu1, N. SaiSwetha2, C. Ramya2, N. Ruksana2, D. Ranjani2

1
Reader and Head of the Department, Department of Public Health Dentistry,
2
BDS, Former Student, Sathyabama Dental College and Hospital, Chennai

ABSTRACT
Objective: To evaluate whether various brands of tooth brushes available in the Indian market adhere to
ADA specified tooth brush design norms.
Methodology: 13 brands of tooth brushes which are commercially available in the Indian market were
selected for the study purpose. Each single tooth brush was compared for the length of the head, width of
the head, number of tufts, number of bristles, diameter of the bristles, and surface area of the brushes with
the standard ADA (American Dental Association) specifications.
Result: Tooth brushes which are classified under soft, medium, hard and extra soft tooth brushes did not
meet the given specifications.10 out of 13 tooth brushes are in accordance with ADA specification related
to length and 1 out of 13 tooth brushes are following related to width, while coming for the number of rows
11 out of 13 are satisfied and 10 out of 13 are satisfied related to number of tufts per row .Finally 13 out of
brushes are not in accordance with ADA when compared to number of bristles/tufts. Some manufactures did
not even provide with the proper type of bristles as per labelling.
Conclusion: There has been a large violation due to improper quality and worst manufacturing of tooth
brushes. Public should get aware of about ADA specifications for the proper tooth brush to purchase and
use by them. 99% of the surveyed brushes did not meet the ADA specifications.

Keywords: ADA specification, Tooth brush design, Oral

hygiene.
Introduction toothbrush by utilizing threadbare twigs 1 As per another
source, around 1600 BC, the Chinese arranged “chew
In the remote past, man needed to find out ways
sticks” that were produced using the twigs of sweet-
innovatively to clean his teeth and make his breath
smelling trees for refreshing their breaths.
pleasant to loved ones. It is not known actually who
initially developed the idea of tooth cleaning, despite the Toothbrush is described as the most classic and
fact that markings on teeth found in caves going back principle method in the oral hygiene practice, since
to the Stone Age put forward the thought that primeval ancient times. Chewing sticks were mostly the first tooth
man utilized alternative toothpicks possibly made from brush designed which were manufactured by
wood or bone that helps to be clear out seeds and bone Babylonians as early as 3500 BC.1.The predecessor of
sections from between his teeth. The growth of the the toothbrush is the “chew stick”. Chew sticks were
initial toothbrush likely goes back to around 3550BC, twigs with frayed ends used to brush the teeth while the
when the Babylonians and Egyptians created the primary other end was used as toothpick. The earliest chew
sticks were discovered in 3550 BC and mentioned in
Chinese records dating from 1600BC. The Greeks and
Corresponding Author:
Romans used toothpicks to clean their teeth and
Dr. V. Anu MDS,
toothpick like twigs have been excavated in ‘Qin
Reader and Head of the Department,
Dynasty’ tombs. Chew sticks remain common in Africa
Sathyabama Dental college and Hospital, Chennai
and the rural Southern Indian states till recent past.
Email: [email protected]
Modern toothbrush has been originated
7 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,&No.
Research 7
Development, July 2019, Vol.10, No. 7 7

in China. The first bristle toothbrush consists of hog of the head (brushing surface), Width of head (using
bristles. They were attached to a handle manufactured vernier callipers): three trials each, Number of tufts per
from bamboo or bone, forming a toothbrush. row, Number of bristles per tuft, Diameter of the
bristles- (soft=0.007inch, medium =0.012inch,
At present, the market is crowded with multiple
hard=0.014inch), Surface area of the brushes, with the
varieties of toothbrushes. Some with effective
Standard ADA specifications8.
advertising which overstates the size, shape and other
features comparing, each superiority over another, The tooth brush was divided into 3 parts - head,
which leaves all the consumers in a state of dilemma to shank and handle. The length of head was measured by
purchase and buy which brand of tooth brush. Thus it using the divider, by placing one end of the divider on
is very essential to ensure the correct guidelines to both top of the head and the other end at the bottom of the
toothbrush manufacturer as well as consumer, so that it head. Then the distance between the two end points were
will help the public to select a proper toothbrush which transferred on to metal scale for the measurement of
length of the head. The width of the head was measured
helps to maintain a good oral hygiene.
by using the divider method and it was measured
Toothbrushes vary in size, design, length, hardness horizontally from one end to another end.
and arrangement of the bristles. There are several
The diameter of the bristle was measured by using
studies, which reports that due to improper tooth the vernier callipers and it was set in accordance with
brushing technique and improper toothbrush design the error ±0.1mm. Single bristle from the tooth brush
there is an increase in cervical abrasion of teeth 2,3 and head was taken from the group of tufts and that single
gingival trauma4. Toothbrush design is a very important bristle was hold in between the upper arm and lower arm
key factor in the maintenance of oral hygiene. If the of vernier callipers. Now the reading was evaluated.
design is not satisfactory there will be improper cleaning Rows of each tooth brush were calculated for three trails
of tooth surface areas which will affect the teeth and and mean of the three trails was recorded. Group of
periodontal health5. Bristles on the other hand , also play tufts which is present in the rows was calculated.
a very important role in the function that,if the bristles
The surface area of each tooth brush was calculated
of the toothbrush are very hard it will lead to bleeding of by using the formula relating to the shape of the tooth
gums4,5. ADA specifications are used for testing the brush design. For the brush code 10,11,12,13 the shape
tooth brush quality for the safety use of the tooth brush of the head is in oval shape - the formulae used for
so that will help to maintain good oral hygiene6. calculating the surface area is A = pr2 where the value
of π is taken as 3.14.cFor the brush codes 1, 4 the shape
Although several studies1,7 have been done related of the head is oval and with rectangle- the formulae used
to tooth brushes, yet there is no confirmation of the for calculating the surface area is pr2 + l × b. For the
toothbrush whether they are following the ADA brush codes 2,6 the shape of the head is in
specification or not. The main objective of the study is triangular
to evaluate the commercially available various – the formulae used for calculating the surface area
brands is

of toothbrushes in the Indian market are similar to 2A = pr2 + 1 b × h. For the brush codes 3, 5 the shape of
2
the
specifications which are advised by ADA. the head is triangular - the formulae used for calculating
1
the surface area is l × b b × h. For the brush codes 7, 8,
Methodology + 2
Each single tooth brush was compared for the
The current study was conducted in the Department Length
of Public health Dentistry, Sathyabama Dental College
and Hospital, Chennai. 13 tooth brushes from 4
commonly available brands , which are commercially
available in the Indian market were selected for the
study purpose. All the tooth brushes have been coded
from 1 to 13. The study of tooth brushes consists of soft,
medium, hard, and very hard varieties of tooth brushes.
8 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,&No.
Research 7
Development, July 2019, Vol.10, No. 7 8
9 the shape of the head is rectangular – the formulae used
1
for calculating the surface area is A = pr2 + 2 × ×h
2b
The method for calculating the surface is done by
observing the tooth brush head and by noting down the
related the formulas. Thus the recorded data was noted
down in the excel sheet. Average mean and the standard
deviation of all the recorded values are then calculated
and noted down. The values thus obtained are compared
with the ADA specification8.
Results On measuring the length and width of toothbrush
head in the order of soft ,medium and hard
Evaluation of bristle diameter gives the information variety(table-
that out of 3only 1 extra soft toothbrushing accordance 1),it was found that 10 out of 13 toothbrushes relating to
with ADA specification no(table-2); out of 5 soft tooth length meet the ADA specifications, while considering
brushes none is with the accordance of ADA the width 3 out of 13 tooth brushes alone meet the
specification no(table-3); out of 4 toothbrushes in ADA specification. While considering the no.of
medium none is satisfying(table -4).The ADA standard rows-
specification out of 1 hard toothbrush is also not with the 11 brushes out of13 are following the ADA
accordance with ADA specification(table-5). standard
specification. While comparing the tufts only 11 out
of
13 met with the ADA specification number and while
comparing the no. of bristles only 1 out of 13 follows
the ADA standard specification (table-1)
Table 1: Specifications of commercially available tooth brushes

Width of Head
Tooth Brush No of No of No of
Length of Head Avg. of 3 SD (standard
Code Rows Tufts/Row Bristles/Tuft
trials inches deviation) inches
1. 1.1333* 1.117* 0.3666 0.42 4* 13 95
2. 1.1* 0.609* 0.4 1.52 4* 11* 50
3. 1.2* 0.09 0.4 0.381* 4* 11* 32
4. 1.366* 0.23 0.4 0.186 4* 12* 55
5. 1.1* 0.0013 0.7 0.54 4* 11* 45
6. 1* 0.3 0.4 0.65 5 11* 52
7. 1.555 5.08 0.5 2.54 4* 11* 50
8. 0.7874 0.55 0.3346* 0.18 3* 9 60
9. 1.1* 0.254 0.5 0.512 5 1 53
10. 1.0143* 1.117 0.444 0.25 4* 10* 54
11. 0.9672 0.41 0.4265 0.72 4* 9* 56
12. 1.0271* 0.28 0.4571 0.16 4* 9* 54
13. 1.0* 0.23 0.4428 0.21 4* 9* 55
Standard ADA
1inches 1.41inch 0.315inch 0.303inch 2-4 5-12 80-86
specifications

*In accordance with ADA specification.

Table 2: Diameter of “Extra soft” Toothbrush Table 3:Diameter of “Soft” Tooth Brushes

Toothbrush Toothbrush
Average Diameter of 3 Bristles Inch Average diameter Standard Standard
Code code of 3 bristles (inch) deviation(SD)
Deviation(SD)
1 0.009 1.345
2 0.007 2.478
4 0.005 3.678
5 0.002 1.590
7 0.004 2.517
8 0.005* 0.323
11 0.008 0.967
*ADA specification no 0.005 inch 12 0.010 2.678
*In Accordance with ADA specification *ADA specification no 0.007 inch
*In accordance with ADA specification
Table 4: Diameter of “Medium” Toothbrushes with proper type of bristles as per labelling. There has
Toothbrush Average diameter Standard been a large violation from ADA specifications due to
code of 3 bristles(inch) deviation(SD) improper quality check by manufacturers’ leading to
worst manufacturing of toothbrushes. There are different
3 0.006 2.286
varieties of toothbrushes available in many colours,
6 0.005 2.184
designs, packages each claimed to be better than
9 0.014 1.212
other
13 0.008 0.456 .The main purpose of using tooth brush with simple
*ADA specification no 0.012 inch design which is following ADA specification is to obtain
*In accordance with ADA specification the best result during brushing. Public should get aware
about the ADA specification for the proper toothbrush
Table 5: Diameter of “Hard” Toothbrush to follow according to the individual. By proper usage
of toothbrush one can avoid many problems faced by
Toothbrush Average diameter Standard the people in day to day life. Good oral health begins
code of 3 bristles(inch) deviation(SD)
from oneself. Good oral health isn’t hard to achieve
10 0.007 1.345 but it does take discipline. Brush your teeth every day
*ADA specification no 0.014 inch to keep the dentist away. But to maintain proper oral
*In accordance with ADA specification condition visiting dentist regularly is not wide of the
mark. The main reason for going to the dentist regularly
Discussion every 6 months is prevention. The goal is to prevent
tooth decay, gum disease, and other disorders that put
This study has been conducted to compare whether the health of your teeth and mouth at risk. Every tooth
the toothbrushes which are commercially available in the in a man’s mouth is a diamond. Hence the manufacturer
market are meeting the standards which are set by ADA of tooth brushes, despite of business purpose, should
specifications given for toothbrush. Toothbrushes which keep in mind the ADA specifications while producing
are classified under soft, medium, hard and extra soft toothbrushes and ultimately extend a moral support
toothbrushes did not meet the specification given by to the people by showing great concern for their oral
ADA. Few brands failed to reach approximate health. There should be a regular check and necessary
specifications of ADA. The greatest disparity was seen measurements should be taken by the government by
with regards to diameter and no of bristles.99% of seeking the help from the Public Health Dentistry side to
surveyed brushes had less bristles than specification, have an inspection regarding the manufactures.
since it is known that plaque removal procedure is
carried out with the brushing technique i.e more based on Ethical Clearence: This study does not involve any
technique rather than type of bristles and if bristles are human sample.
not satisfactory adverse changes are observed with
Source of Funding: Self
brushing like abrasion of tooth surface, Traumatizing the
gingival margin, so the need of hand bristled tooth Conflict of Interest: Nil
brushes in the market is doubtful. Many toothbrushes did
not follow the ADA specification for length ,width of
REFERENCES
head, all being larger than norms. Small head
toothbrushes help in improving plaque removal. 1. Bhat MK, Dhiraj.S, Thomas.B. Tooth brush a
Astonishingly none of the evaluated toothbrushes totally dilemma, Indian Journal of Dentistry 2006;17(4):
satisfied the specifications of ADA. Detailed descriptions 167-170.
of the toothbrushes available in the market are given in 2. Dickson WJ, Vandewalle KS, Lien W, Dixon
this study which is deviated from the normal existing SA, Summitt JB. Effects of cyclic loading and
specifications. This findings is similar to studies done by toothbrush abrasion on cervical lesion formation.
Bhat MK(2006)1 and Singh Walia S(2016)8. J Acad Gen Dent. 2015;63:e1-5.
Majority of the manufacturers did not specify about 3. Hakeem S, Baqar A, Mohsin A, Ilyas F, Monpuri
bristles per tuft. Some manufacturers did not even A, Hassan F. Investigation of abrasion related
provide
tooth surface loss and its association with oral analysis. International journal of dental
hygiene behaviours. Pakistan Oral & Dental hygiene.
Journal. 2017 Dec 1;37(4). 2018 Feb;16(1):3-12.
4. Heasman PA, Holliday R, Bryant A, Preshaw PM. 6. Nayak GD, Ashita Uppoor. Periodontology and
Evidence for the occurrence of gingival recession Oral Implantology; 2nd edition :356
and non‐carious cervical lesions as a consequence
7. Singh Walia S, Randhawa AK, Malhotra S,
of traumatic toothbrushing. Journal of clinical
Multani K, Kaur G. Comparison Of
periodontology. 2015 Apr 1;42(S16).
Commercially Marketed Toothbrushes In
5. Hoogteijling FC, Hennequin‐Hoenderdos NL, Amritsar-In Accordance To Ada Specification.
Van der Weijden GA, Slot DE. The effect of Indian Journal of Comprehensive Dental Care
tapered toothbrush filaments compared to end‐ (IJCDC). 2016 Jan 1;6(1).
rounded filaments on dental plaque, gingivitis and
8. Saunders, Carranza FA; Clinical Periodontology:,
gingival abrasion: a systematic review and meta‐
2005, 11th edition:, 651-654.
DOI Number: 10.5958/0976-5506.2019.01529.8

Maternal Mortality at a Tertiary Care Hospital in North India:

A 4 Year Review

Pratima Mittal1, Garima Kapoor2, Bindu Bajaj3

1
Consultant & HOD, 2Associate Professor, 3Consultant & Associate Professor, Obs. &
Gynae., VMMC & Safdarjung Hospital, New Delhi

ABSTRACT
Worldwide, almost half a million maternal deaths occur every year. Most of these deaths (99%) occur in
developing countries. South Asian countries which includes India. Most maternal deaths are preventable as
the medical interventions necessary to treat or prevent complications are well established. Even then, the
progress made in maternal health so far is unsatisfactory. This study was conducted to determine the causes
and epidemiological factors that lead to maternal deaths at a Tertiary care hospital in North India, and
henceforth, suggest measures to reduce maternal mortality in the region. It was a retrospective study. The
female deaths at the Institution which met the WHO Criteria for Maternal Death during the year 2013-2016,
were analyzed for epidemiological factors and causes of maternal deaths. During the study period there
were 364 maternal deaths. Maternal mortality ratio in the study period was 358.73, 273.30, 371.45 and
436.61 in the year 2013,
2014, 2015 and 2016, respectively. Majority of the women who died (73.07%) were in the age group of 21-
30 yrs. Most of the women (70.32%) were multipara (56.59%) and grand-multipara (13.73%). Most of the
women were un-booked( 88.46%).Direct causes still contributed to majorly of maternal deaths [ hypertensive
disorders (28.02%), pregnancy related infections (20.87%), and hemorrhage (12.36%)]. Among indirect
causes, anemia and hepatitis were most common (15.93% & 11.53%, respectively). Promoting good quality
antenatal care for all, universal iron supplementation, strengthening the infrastructure of peripheral Health
facilities and forming a referral network are some of the measures that may help reduce maternal mortality.

Keywords: Maternal mortality review, retrospective study, tertiary care hospital, North
India.
Introduction maternal health so far is unsatisfactory. United Nation
(UN) report card on Millennium Development Goal-5
Worldwide, approximately 830 women die every
concluded that the progress shown by the South Asian
day due to complications of pregnancy or childbirth1.
countries including India is unsatisfactory. These
This amounts to almost half a million maternal deaths
countries have achieved a decline of MMR by
every year. Most of these deaths (99%) occur in
around
developing countries. South Asian countries which
20 percent against a target of reducing MMR by 75 per
includes India, accounts for nearly one- third of the
cent between 1990 and 20152. For India, it implied that
global burden of maternal deaths.2
it should have achieved the target of reducing maternal
Most maternal deaths are preventable as the medical deaths to 109 by 2015. However, it failed to achieve its
interventions necessary to treat or prevent complications target, and has only achieved an MMR of 174.
1

are well established. Even then, the progress made

This study, was conducted to determine the causes
in
and epidemiological factors of maternal deaths at a
Tertiary care hospital in North India, and henceforth,
suggest measures to reduce maternal mortality in the
Corresponding Author: region.
Dr Garima Kapoor
Associate Professor, Obs. & Gynae. Aims & Objectives
VMMC & Safdarjung Hospital, New Delhi
Email: [email protected]
1. To determine & compare the Maternal Mortality
ratio at the Tertiary care Hospital for a period of
four years.
12 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 12

2. To identify the causes that led to maternal deaths of 364 maternal deaths. Maternal mortality ratio in the
at the Institution. study period was was 358.73, 273.30, 371.45 and 436.61
3. To suggest measures to reduce maternal in the year 2013, 2014, 2015 and 2016, respectively.
mortality. The epidemiological characteristics of the maternal
death cases are shown in Table 1.
Materials & Method
Majority of the women who died (73.07%) were
It was a retrospective study conducted in a tertiary in the age group of 21-30 yrs. Adolescent pregnancy
care hospital, in north India, with an annual delivery rate attributed to 3.29% (n=12) of maternal deaths. Most of
of around 26-27,000. The hospital receives several un- the women (70.32%) were multipara (56.59%) and
booked patients and referral cases from private and public grand- multipara (13.73%). Nearly two- thirds of the
maternity homes, hospitals and Medical colleges across women (68.68%) belonged to lower socioeconomic
Delhi and neighboring states. The hospital runs 3 ICU’s, strata. Most of the women were un-booked, an
an Obstetric HDU. It also has blood bank facility and 2 alarmingly 88.46%. Nearly 2/3rd of these un-booked
emergency operation theatres, functional round the clock cases (64.9%) were referred from other centers, often
to provide emergency obstetric services to its patients. after life-threatening complications. Many of these
women were brought to the hospital in critical (94,
The female deaths at the Institution which met the 29.12%) and serious (102,
WHO Criteria for Maternal Death1 were included in this 31.67%) conditions, respectively.
study: All female deaths, while pregnant or within 42
days of termination of pregnancy, irrespective of the Type I (64.28%) and type II (49.45%) delay
duration and site of pregnancy, from any cause related to were
or aggravated by pregnancy or its management but not the most common delays identified in this study
from accidental or incidental causes 1.
The causes of maternal deaths were classified
The details of all the maternal deaths for a period according to the WHO Application of ICD-10 to deaths
of four years, from January 2013 to December 2016 during pregnancy, childbirth and puerperium4 and
were collected from the Maternal mortality register and summarized in Table 2.
the case sheets. This data was analyzed with respect to Table 1: Socio-demographic characteristics of
the following parameters:- age, parity, socioeconomic women who died
status, residence, booking status, condition on Socio-demographic character No. of women (%)
admission, prevalence of anemia, admission death Age
≤ 20 years 46 (12.63%)
interval, causes of death and type of delays identified. 20-30 years 266 (73.07%)
31-40 years 46 (12.63%)
Maternal mortality ratio was calculated by using the > 40 years 06 (1.64%)
formula- Booking status
Unbooked 322 (88.46%)
Total no. of maternal deaths ×100, 000 Booked 29 (7.96%)
MMR =
Total no. of live births Registered 13 (3.54%)
Types of delay according to WHO is summarized
3 Status on admission (AHA) 21

Good 19 (5.21%)
as follows- Fair 54 (14.83%)
z Type I delay: delay in the decision to access care Serious 171 (46.97%)
Critical 120 (32.96%)
z Type II delay: delay in the identification of and Prevalence of Anemia
transport to a medical facility Severe (˂7 gm%) 133 (36.53%)
Moderate (7-9.9 gm%) 129 (35.43%)
z Type III: delay to the receipt of adequate and Mild/ No (≥10 gm%) 112 (30.76%)
appropriate treatment Referral
Referral 211 (57.96%)
No Referral 153 (42.03%)
Results Duration of Hospital stay
≤24 hours 164 (45.05%)
During the study period, from January 2013 to 24-48 hours 72 (19.78%)
December 2016 there were 100,631 live births and total > 48 hours 128 (35.16%)
Table 2: Causes of Maternal Deaths
Groups according to
Type and Group No. of Maternal Deaths (%)
ICD-10 Code4
1 Direct: Pregnancies with abortive outcome 10 (2.74%)
2 Direct: Hypertensive disorders 102 (28.02%)
3 Direct: Obstetric hemorrhage 45 (12.36%)
4 Direct: Pregnancy related infections 76 (20.87%)
5 Direct: Other obstetric complications
Obstructed labor 08 (2.19%)
Direct: Unanticipated complications of management
6 13 (3.57%)
(eg. pulmonary embolism)
7 Indirect: Non obstetric complications
Anemia 58 (15.93)
Heart disease (with or without pre existing
12 (3.29%)
hypertension)
Gastrointestinal complications 55 (15.10%)
Respiratory diseases/ARDS/TB 20 (5.49%)
Neoplasm 02 (0.54%)
Infections, not direct result of pregnancy 02 (0.54%)
Epilepsy 02 (0.54%)
8 Unspecified: Unknown/Undetermined 03 (0.82%)
9 Coincidental causes 0

Table 3: Review of literature: Causes of maternal deaths in different studies

disorders of
Hypertensive
Direct cause

Heart Disease
Anemia

Miscellaneous
Jaundice
MMR

Sepsis
Hemorrhage

Indirect
Author

pregnancy

Murthy et al
16 302.23 72.5% 26.66% 18.33% 26.66% 27.5% 10% 9.16% 3.33% 5%
( 2013)
Vidyadhar et
302.9 50% 21.05% 7.89% 10.52% 50% 2.63% 21.05% 13.15% 13.15%
al14 (2011)
Jadhav et al
15 395 43.64% 27.84% 3.16% 10.75% 56.36% 33.33% 7.59% 10.75% 4.69%
( 2013)
Das R al 17
518.48 81.64% 21.87% 13.28 % 16.3% 18.35% 2.74% 6.64%
(2014)
Puri et al 19
690 55.38% 12% 24% 18% 14% 13% 14%
(2011)
V Saini et 471.54-
60.5% 23.9% 21.1% 7% 39.43% 8.4% 9.8% 2.8% 9.8%
al20( 2014) 225.57
V P Paily et 33.9-
48.90% 22.55% 8.38% 15.57% 51.1% 1.20% 6.79% 6.39%
al.10 ( 2014) 31.3
Mittal et al
361.71 69.81% 12.36% 20.87% 28.02% 30.19% 15.93%
(2017)
Discussion seek care (234, 64.28%) and delay in reaching tertiary
care center (180, 49.45%). Another Indian study 12
Maternal mortality is an index of quality of
also reported a high type I (85.89%) and type II delay
Maternal Health services and the socio-economic status
(10.25%).
of a community or a nation. Hence, a high maternal
mortality not only reflects poor quality of Health Also, lack of availability of blood and blood
services and referral linkages, but also a lack in the components/ blood bank, emergency obstetric care
Socio-economic development and infrastructure of a facility, trained manpower, ICU facility at various
community. centers across the state and neighboring states have been
identified. This often leads to patient being referred from
The Maternal mortality ratio in the study period
one facility to the other without receiving appropriate
was 358.73, 273.30, 371.45 and 436.61 in the year
medical care. No proper referral linkages also lead to
2013, 2014, 2015 and 2016, respectively. MMR in our
delay in a women receiving access to a referral center.
study still remains quite high, more than our national
average (174/100,000 live births1. Similar high maternal Most of the women in our study were in the age
mortality has been reported by other Indian studies as group of 21-30 years (73.07%); similar to other studies
well (Nishu Priya et al 5 at 270/1,00,000 live births, across India6,7,13 . Adolescent maternal death were seen
Ashok et al6 at 345.9/1,00,000 live births, VB Bangal in 12 cases (3.29% of total maternal deaths), as against
et al7 at 302.9/1,00,000 live births, Purandare et al8 a total occurrence of 7% adolescent pregnancies in this
at Institution. Other Indian studies have reported a higher
113/1,00,000 live births, Sundari KPM et al9 at 559- incidence of mortality in adolescent girls ( Vidhyadhar
802/1,00,000 live births.). Only, one Indian study from et al.14 : 15.79%, Jadhav et al15: 9.49%, Murthy et
Kerala has reported a very low MMR of 33.9/100,000 al :
live birth 10. This is because, Kerala state has the lowest 5.83%16,Das R et al.17 : 30.85%). UN statistics division
maternal mortality in the country. On analysis of the reported adolescent pregnancy in India as 86/1000
data, the high maternal mortality in the study, can be (1995-2010), which is very high as compared 49
explained by the fact that the health facility being a globally and 53 in less developed countries. The main
Tertiary care center, receives referrals of several un- causes for teenage maternal deaths in this study were
booked patients, often with life threatening septic abortion (41.66%), pre eclampsia and eclampsia
complications from various hospitals (public and (33.33%), sepsis (23.91%), anemia (16.66%).
private) in and around Delhi. Pathak et al11 also
reported a high MMR of 428-869.6/ Majority of the women who died in this study were
100,000 live births also due to large number of referral multipara and grand-multipara comprised 56.59%
cases. Majority of the women in the study, were un- and
booked (322, 88.46%) and most of them referred from 13.73%, respectively. Hence, highlighting the need to
other public/private facility. Many presented to us in strengthen family planning services. In grand multipara
serious (31.67%) or critical condition (29.12%) often group, 20% deaths were due to hypertensive disorders,
with multiple complications and expired within 24 hours anemia and respiratory diseases each.
of admission to the hospital (45.05%). Also, with the
Majority (69.81%) of maternal deaths were due
establishment of an Obstetric HDU in the Department,
in 2016, there was a significant rise in the number of to direct obstetric causes; Hypertensive disorders
referred cases from 49.47% in 2015 to 59.48% in 2016. (28.02%), pregnancy related infections/sepsis (20.87%),
Moreover, the number of patients who presented in a hemorrhage (12.36%), and abortion (2.74%). Other
Critical condition at admission, increased from 32.63% studies from across India have also reported a high
in 2015 to 50% in 2016. Many were transferred 62 incidence of Maternal deaths due to direct causes
(29.38%) without adequate life support measures, (Table 3)
,15,16,17,18
. As per WHO (2007 & 2010) 25% of
further aggravating their moribund state. Hence, all maternal deaths world-wide are due to hemorrhage.
explaining the rise in Maternal Mortality in 2016. In our study obstetric hemorrhage contributed to
only
Many of these patients could have been saved by 12.36% of cases, much lower than other Indian studies
timely and early access to Health care services. The (Murthy BK et al16 26.66%, Ann L. Montgomery et
most common delays identified in this study were Type
I and Type II delays. No ANC and delay in deciding to
al18 27%, Nishu Priya et al8 35.05%). This is probably,
because the hospital runs blood bank facilities round the
clock with availability of various blood components. 10. Maternal death review and audit
Anemia was significant co morbid factor (71.97%) and
11. Identifying Maternal Early Warning Signs in
an indirect cause of maternal mortality in 15.93% in this
mothers at referring Centres, ( MEOWS Score) to
study which is comparable to study done by Khandale
ensure early and timely referrals, easy transport
SN et al12 (14.10%).
and with adequate life support measures.

Conclusion 12. Sex education to teenagers.

Most of the maternal deaths in this study were Source of Funding: No funding sources
observed in women from rural areas who were less Conflict of Interest: None declared
educated, with no antenatal coverage and belonged
to lower socioeconomic status. Maternal death is an Ethical Approval: The study was approved by the
avoidable tragedy and most of the causative factors can Institutional Ethics committee
be prevented to a large extent.
REFERENCES
From this study it was c oncluded that Direct
causes like Hemorrhage, sepsis & hypertensive disorders 1. World health statistics 2017: monitoring health
of pregnancy, still contribute to majority of maternal for the SDGs, Sustainable Development Goals
deaths. Anemia, Heart disease and Jaundice were the 2. The Millennium Development Goals Report 2009.
major medical causes of Maternal deaths in this study. New York: United Nations; 2009. Association
Hence, the following measures are suggested to reduce of Health Care Journalists, American Hospital
the National MMR to achieve the desired MMR of 100 Association. 2014
by the year 2020.
3. Emilie J C, Alexander P S, Andrea G T & Lee A
1. Ensuring 100% antenatal coverage for all W. Applying the lessons of maternal mortality
pregnant reduction to global emergency health. Bulletin of
women & promoting institutional deliveries. the World Health Organization 2015;93:417-423.
2. Promoting oral iron supplementation along with 4. The WHO application of ICD-10 to deaths during
dietary advice for correction and prevention of pregnancy, childbirth and puerperium: ICD MM.
anemia. 2012
3. Measurement of Blood pressure at each antenatal 5. Nishu P, Verma A, Verma S. Maternal Mortality:
visit to ensure early identification and Ten years Retrospective Study. JK science.
management of pre-eclampsia. Journal of Medical education and Research.
2010;12(3):134-136.
4. Initiation of Anti-hypertensives at BP above
150/100mmHg and timely referral of these 6. Verma A, Minhas S, Sood A. A study of Maternal
patients to tertiary care facility. Mortality. J. Obstetric Gynaecol India. 2008;
58:
5. Training ANMs at CHC, PHC, to administer
226 – 229.
intramuscular Magnesium sulfate for prevention/
treatment of ecclampsia 7. VB Bangal, Purushotham A Giri, Garg R.
Maternal Mortality at a Tertiary Care Teaching
6. Provision of safe abortion services.
Hospital of Rural India: A Retrospective Study.
7. Strengthening of existing Emergency obstetric Int J Biol Med Res. 2011; 2(4): 1043 – 1046
care (EmOC) facilities.
8. Purandare N. Singh A, Upahdya S, et al. Maternal
8. Implementing Active management of 3 stage of
rd
mortality at referral centre: a five year study. J.
labor and systematically observing the 4th stage of Obstetric Gynaecology India. 2007; 57(3): 248–50.
labor. 9. Sundari KP, Jayanthi RD, Ramasamy B. Trends
9. Promotion of family planning services and in maternal mortality in a tertiary care hospital.
spacing of births. Int J Reprod Contracept Obstet Gynecol 2016; 5:
3659-62.
10. Paily VP, Ambujam K, Rajasekharan Nair V, 17. Das R, Biswas S and Mukherjee A. Maternal
Thomas B. Confidential Review of Maternal Mortality at a Teaching Hospital of Rural India:
Deaths in Kerala: a country case study. BJOG A Retrospective Study. International Journal of
2014; 121(Suppl. 4): 61–66. Biomedical And Advance Research (2014) 05
11. Pathak D, Chakraborty B, Goswami S, Adhikari (02) ISSN: 2229-3809 (Online) Journal
S. Changing trends of maternal mortality: A DOI:10.7439/ ijbar CODEN:IJBABN
comparative study. J Obstet Gynae India. 18. Montgomery AL, Ram U, Kumar R, Jha P,
2011; for The Million Death Study Collaborators
61(2):161-5. (2014) Maternal Mortality in India: Causes and
12. Khandale SN, Kedar K. Analysis of maternal Healthcare Service Use Based on a Nationally
mortality: a retrospective study at tertiary care Representative Survey. PLoS ONE 9(1): e83331.
centre. Int J Reprod Contracept Obstet https://doi.org/10.1371/journal.pone.0083331
Gynecol 19. Puri A, Yadav I, Jain N. Maternal mortality in
2017; 6:1610-3. an urban tertiary care hospital of north India.
13. Kaur D, Kaur V, Yuel VI. Alarmingly Journal of Obstetrics and Gynaecology of
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2007; 9(3): 123 – 126. 0042-7.
14. Bangal VB , Giri PA , Garg R. Maternal Mortality 20. Saini V., Gupta M. International Journal of Basic
at a Tertiary Care Teaching Hospital of Rural and Applied Medical Sciences. 4(1):59-64. ISSN:
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April, pp. 59-64/ Saini and Gupta
15. Jadhav CA, Prabhakar G, Shinde MA, Tirankar
VR, Maternal Mortality: Five year Experience in 21. Association of Health Care Journalists, American
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tertiary care hospital: A 10 yr review International
Journal of Preventive Medicine. 2013; 4(1):105-9.
DOI Number: 10.5958/0976-5506.2019.01838.2

Dose Response Relationship of Child Centered Task Oriented

Training in Children with Cerebral Palsy-A Randomized
Controlled Study. Study Protocol

Kovela Rakesh Krishna1, Dhanesh Kumar K U2

1
Assistant Professor, 2Professor & Principal, Nitte Institute of
Physiotherapy, Nitte (Deemed to be University), Deralakatte, Mangalore,
Karnataka

ABSTRACT
Background: Growing child has innumerable capabilities which can impact his recovery if utilized
appropriately. Physiotherapeutical approaches involve child in the treatment and give importance in
framing of goals directed by the therapist. Child centered task oriented training completely gives
importance to the child in planning and performing activities useful for his recovery.
Objective: Primary Objective of the study is to establish the dose response relationship of child centered
task oriented training in children with Cerebral palsy. Secondary Objectives of the study: To establish dose
response relationship of child centered task oriented training on Gross Motor function, Balance and quality
of life in children with Cerebral Palsy.
Method: 80 children with Cerebral Palsy will be recruited and will be divided into two groups.
Experimental group receives Child Centered Task Oriented Training; Control group receives Conventional
physiotherapy. Both groups receive treatment for 45 minutes a day, 2 days a week for 15 weeks. Gross
Motor Function, Balance and Quality of life will be measured Pre Treatment, at the end of 8 weeks and
Post treatment.
Results: The study is expected to begin enrolment in June 2018. We anticipate that the experimental group
receiving Child centered task oriented training study will have superior outcomes when compared to the
control group. From clinical experience this is especially true for children with cerebral palsy as their will
be more functional recovery when we give importance for them to choose what they want.
Conclusion: We believe this will be an important study to assess a novel method to improve the Functional
recovery in children with cerebral palsy. It is simple to apply and monitor the progression.

Keywords: Cerebral Palsy, Physiotherapy, Gross Motor Function, Balance, Quality of life, Rehabilitation,
Child centered task oriented training.

Introduction

Cerebral Palsy(CP) defines a group of permanent

disorders of the development of movement and posture,
causing activity limitation, that are attributed to non-
progressive disturbances that occurred in the developing
Corresponding Author: fetal or infant brain. The motor disturbances of cerebral
Kovela Rakesh Krishna palsy are often accompanied by disturbances of
Assistant Professor, sensation, perception, cognition, communication and
Nitte Institute of Physiotherapy, Nitte behaviour, by epilepsy and by secondary
(Deemed to be University), Deralakatte, musculoskeletal problems 1

Mangalore, Karnataka-575018
Phone: 7204346274 Prevalence of cerebral palsy in developed countries
Email: [email protected] is 2 per 1000 live births and neonatal survivors2.
Cerebral palsy is classified on the basis
of topography
18 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

into monoplegia, diplegia, hemiplegia and quadriplegia3. domain had a great impact on functional disability.
Common impairments in CP include spasticity, Many approaches in recent times focused on active
contractures, weakness of muscles, speech and learning participation of the child in his recovery. Growing child
problems, cognitive and perceptual skills, impaired has innumerable capabilities which can impact his
trunk control, visuomotor, balance and gait issues.4 recovery if utilized appropriately. Physiotherapeutical
approaches involve child in the treatment and give
Balance is defined as the ability to keep the center
importance in framing of goals directed by the therapist.
of mass over its base of support.5 Children with cerebral
Child centered task oriented training completely gives
palsy (CP) may have impaired muscle tone and
importance to the child in planning and performing
abnormal postural control. Both affect functional
activities useful for his recovery. Literature suggests
balance capacity. As balance skills are an integral part of
that 15 weeks’ child centered task oriented training is
gross motor abilities, poor balance causes difficulties
effective in improving balance in children with Cerebral
with functional tasks involved in activities of daily
palsy.8 There is dearth in the literature which clearly
living.6
states whether 15 weeks is mandatory or improvement
Quality of life is usually described as an overall can be achieved by 8 weeks with said protocol in terms
assessment of wellbeing across various domains. It is of Gross motor function, balance and quality of life.
essential in children with cerebral palsy to assess their
Study Rationale: If a dose response relationship is
life in several aspects, including physical wellbeing,
established for improving gross motor function, balance
social wellbeing, emotional wellbeing, school, access to
and quality of life in children with cerebral palsy, based
services and acceptance by others.7
on the frequency of sessions and duration of each
There are various approaches proved to be session and overall treatment time, it will have a great
beneficial in the management of children with cerebral influence on disabled children, their families and society
palsy including Neurodevelopmental Therapy (NDT), in accepting the treatment approach in the recovery
Roods approach, Proprioceptive Neuromuscular of the child. Child enjoys the sessions as there are no
Facilitation (PNF), Constrained induced Movement restrictions and much commands. Family can involve in
Therapy and Task oriented approaches etc. the treatment and help their children, Physiotherapist
will get time in concentrating on more number of
Task oriented training improves muscle strength and children at the same time.
motor skill by repeated training of activity tasks of daily
life. Child centered task oriented training is a method
that supports interesting tasks for children with CP and Materials and Method
leads to effective functional movements. Intentional Study Participants and Setting: 80 Children with
repetitions of activity play’s a major role in interacting Cerebral Palsy of either gender between 6 to 10 years
child with environment. Childhood is the period where will be recruited from Justice KS Hegde Charitable
a child has to actively involve with the peer group either
Hospital, Mangalore.
in school or while playing which enables him identify
his caliber.8 Duration: The study will be carried over for a period of
3 years or till the entire sample size is completed.
In the field of physical activity dose refers to the
amount of physical activity performed by the person.
The total dose or amount is determined by three Objectives
components. 1) Frequency is commonly expressed in
Primary Objective of the study is to establish the dose
sessions or bouts per day or per week. 2) Duration is the
response relationship of child centered task oriented
length of time for each session of any specific
training in children with Cerebral palsy.
activity.
3) Intensity is the rate of energy expenditure needed to Secondary Objectives of the study: 1)To establish
perform the activity to accomplish the desired function dose response relationship of child centered task
(aerobic activity) or the magnitude of the force exerted oriented training on Gross Motor function in children
during strengthening physical activity.9 with Cerebral Palsy.2)To establish dose response
Physiotherapy plays a vital role in improving child’s
functional activities. Introduction of ICF into health
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 19
relationship of child centered task oriented training on Research Design: Assessor blinded Randomized
balance function in children with Cerebral Palsy.3)To Controlled trial
establish dose response relationship of child centered
task oriented training on Quality of life in children with Treatment: Child-centered task-oriented training
Cerebral Palsy. program receives Vestibular set, Doing the splits on a
hammock with swaying back and forth, side to side.
Inclusion and Exclusion criteria: Inclusion Criteria On Swing Lying on one side with swaying back and
will be Children diagnosed with cerebral palsy,Either forth, side to side. Playing quoits. On Roll Moving from
Gender with age 6 to 10 years, GMCS LEVEL I, II,
side to side, rolling. Lying and rolling on a Physio ball,
III, Pediatric MMSC score of 24 or above. Exclusion
bouncing while sitting on a physioball. Keep balance
criteria will beany structural deformities of spine hip
while lying down, sitting, and standing on sway board.
and pelvis,Recent spinal surgeries(3months), Botulinum
Activity while standing like Weight bearing, walking
toxin in last 6 months, Children who are already under
while holding a bar. Walking on a balance beam,
physiotherapy treatment or under anti-spastic, anti-
epileptic medication. spinning in one place. Activity on a mat (5 cm thick)
like Rolling, weight bearing from side to side while
Procedure: Approval taken from Institutional Ethical sitting. Movement (pushing a ball), standing up from
Committee of Nitte Institute of Physiotherapy. (NIPT/ sitting, walking. Activity of proprioceptive sensibility
IEC/Min/014/2017-2018/dated 21-04-2018) like Joint movement (extensional movement), pulling
toward themselves (tug-of-war, chin-up). Muscular
Children diagnosed with CP of either gender
between strength of upper/lower extremities (dumbbell exercise).8
6 to 10 years will be recruited from physiotherapy
Participants in the control group receive
department Justice KS hegde Charitable hospital and
conventional physical therapy focused on improving
pediatric community outreach centers associated with
walking and balance through facilitation and
Nitte University. Screening will be done for inclusion
normalization of movement patterns which involves
and exclusion criteria, study procedure will be explained
to the parents and children, consent and ascent formswill General stretching, range of motion exercises, weight
be taken from parents and children respectively for bearing, Balance and gait training.9
participating in the study. Demographic data including
Outcome Measures: Gross motor Function Measure
age, gender, height and weight of children will be taken
(GMFM-88),Paediatric Balance Scale (PBS), Cerebral
along with type of CP.
Palsy Quality of Life (CP-QOL.
The included subjects will be divided in to two
groups interventional group and control group by Results
randomly dividing through computer generated table.
Allocation will be done through sequentially numbered The study is expected to begin in the month of June
opaque sealed envelope. 2018. Ethical approval has been obtained for the study.
CTRI registration is under process (already applied).
Before the beginning of the study evaluation of From past literature and clinical experience Child
balance through pediatric balance scale(PBS), Gross centered Task oriented training may prove beneficial
motor function through GMFM-88 and Quality of Life
than control group.
by CP QOL will be taken. The intervention group will
receive child centered task oriented training for 45min
Discussion
per session, 2 times a week for 15weeks. Control
group receives Standard Conventional therapy 30 If the Dose response relationship is proved to be
min per session, two sessions per week for 15 weeks. beneficial it can reduce the number of sessions a child
Reassessment will be taken after completing 8th week
has to visit the hospital, it can decrease the load on
and 15th week by an assessor with similar experience
parent and therapist as the child is active participant. It
who is blinded for the intervention in both Experimental
can motivate the child to do more challenging tasks.
and control groups.
20 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Conclusion the population: Results from a large UK birth

cohort study. International Journal of Pediatric
Child centered task oriented training is a simple
Otorhinolaryngology. 2011;75(1):106-113.
program where no specific training is required. Child is
active participant and will be motivated to perform the 6. Gan S, Tung L, Tang Y, Wang C. Psychometric
activities by himself. As the study is yet to start we are Properties of Functional Balance Assessment in
hoping for a good research project as we are going to Children with Cerebral Palsy.
conduct this study on large population and for 3 years. NeuroRehabilitation and Neural Repair.
2008;22(6):745-753.
Conflict of Interest: None
7. Waters E, Davis E, Mackinnon A, Boyd R,
Source of Funding: The material required for the study Graham H, Kai Lo S et al. Psychometric
will be provided by Nitte (Deemed to be University), properties of the quality of life questionnaire for
Deralakatte, Mangalore. children with CP. Developmental Medicine &
Child Neurology.
REFERENCES 2006;49(1):49-55.

1. Rosenbaum P, Paneth N, Leviton A, Goldstein 8. Kim Y, Lee B. Clinical Usefulness of Child-

M, Bax M, Damiano D, et al. A report: the centered Task-oriented Training on Balance
definition and classification of cerebral palsy Ability in Cerebral Palsy. Journal of Physical
April 2006. Developmental Medicine & Child Therapy Science. 2013;25(8):947-951.
Neurology. 9. Hagströmer M, Franzén E. The importance of
2007;49:8-14. physical activity and health for physical therapy.
2. Pakula A, Van Naarden Braun K, Yeargin- Physical Therapy Reviews. 2017;:1-8.
Allsopp M. Cerebral Palsy: Classification 10. Salem Y, Godwin EM. Effects of task-oriented
and Epidemiology. Physical Medicine and training on mobility function in children
Rehabilitation Clinics of North America. with cerebral palsy. NeuroRehabilitation.
2009;20(3):425-452. 2009;24(4):307-13.
3. Tecklin J. Pediatric Physical Therapy. 4th ed. 11. Ko J, Kim M. Reliability and Responsiveness
Philadelphia, Pa: Lippincott Williams & Wilkins; of the Gross Motor Function Measure-88 in
2008. Children with Cerebral Palsy. Physical
4. Shepherd R. Physiotherapy in paediatrics. 3rd ed. Therapy.
London: Pa: Elsevier/Butterworth-Heinemann; 2012;93(3):393-400.
1995. 12. Her J, Woo J, Ko J. Reliability of the Pediatric
5. Humphriss R, Hall A, May M, Macleod J. Balance Scale in the Assessment of the Children
Balance ability of 7 and 10-year-old children with Cerebral Palsy. Journal of Physical Therapy
in Science. 2012;24(4):301-305.
DOI Number: 10.5958/0976-5506.2019.01530.4

Association between Obesity and Elevated Blood Pressure

among School Going Adolescents–A Cross Sectional Study

Lipilekha Patnaik1, Sumitra Pattnaik1, Trilochan Sahu2, E. Venkata Rao3, Saswatika Beura4
1
Professor, 2Professor & Head, 3Professor, 4Junior Research Fellow, Department of Community
Medicine, IMS & SUM Hospital, Bhubaneswar, Dist.: Khordha State: ODISHA

ABSTRACT
Background: Adolescent overweight and obesity is an issue of epidemic proportions worldwide and it
is related to elevated blood pressure among them. Hypertension in the context of overweight and obesity
indicates a higher potential for cardiovascular disease (CVD) than is associated with either risk factor
alone.
Objectives: To find out the relation between overweight / obesity and elevated blood pressure among
school
going adolescents.
Method: A school based cross-sectional study was conducted in 1800 adolescents of 10-16 years.
Anthropometric parameters like BMI and blood pressure (BP) were measured using standard guidelines.
Results: Prevalence of elevated BP increased with increase of nutritional status. Elevated blood pressure
was observed significantly higher among overweight/obese adolescents (P=0.000). As BMI and waist
circumference increased, SBP and DBP increased and correlation was significant at 0.01 level.
Conclusion: All overweight/obese adolescents should be screened for hypertension and early intervention
measures should be taken for weight reduction and BP control.
Keywords: Hypertension, Teens, Body
weight
Introduction cardiovascular diseases. It is the leading cause of death
and disability worldwide and accounted for 9.4 million
Adolescent overweight and obesity is an issue
deaths and 7% of disability adjusted life years (DALYs)
of epidemic proportions worldwide.1 An increasing
in 2010.3 In India, it is the leading Non Communicable
number of studies suggest that adolescent overweight
Disease (NCD) risk and estimated to be attributable for
has been linked to comorbidities such as dyslipidemia,
nearly 10% of all deaths.4
nonalcoholic steatohepatitis, diabetes mellitus type 2,
obstructive sleep apnea, and hypertension.2 Globally Overweight adolescents with hypertension have
raised blood pressure is a major public health problem of a higher likelihood of both elevated weight and
concern because of its association with increased risk of BP persisting into adulthood.5,6 In addition, some
complications of obesity are independently related
to elevated BP, such as obstructive sleep apnoea.7
Studies have shown that the level and patterns of blood
Corresponding Author:
pressure among children and adolescents may vary from
Dr. Lipilekha Patnaik
population to population.8 The prevalence of childhood
Professor, Dept. of Community Medicine
hypertension in various Indian studies range from 0.96%
Institute of Medical Sciences & SUM Hospital to 11.4% respectively.9 Hypertension in the context of
Siksha ‘O’ Anusandhan Deemed to be overweight and obesity indicates a higher potential for
University, Sector-8, Kalinga Nagar, Ghatikia, cardiovascular disease (CVD) than is associated with
Bhubaneswar-751003 either risk factor alone. Results from the Bogalusa
Mobile: +91-9437322268 Heart Study demonstrated that multiple risk factors
Email: [email protected], in childhood have multiplicative rather than additive
[email protected] effects on the severity of coronary artery lesions.10
22 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

(BMI <3rd percentile), normal (BMI 3

rd
Owing to the relation between elevated percentile
blood pre rel
ssu ate
re ov
an er
d we
ov igh
er t/o
we bes
igh ity
t/o an
bes d
ity ele
am vat
on ed
g blo
ad od
ole pre
sce ssu
nts re
an am
d on
av g
ail sch
abi ool
lity goi
of ng
lim ad
ite ole
d sce
dat nts
a .
fro
m Meth
Od
T
ish
his
a,
sch
an
ool
att
-
em
bas
pt
ed
has
cro
be
ss-
en
sec
ma
tio
de
nal
to
stu
23 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
dy was conducted from without shoes to the to adult equivalent Data were analyzed d m
July to December 2013, nearest 100 grams. Blood of BMI <23), using SPSS 20.0 o
o n
in 12 schools a city of pressure (BP) was overweight (Adult licensed to the b
Eastern India. Sample measured with a standard equivalent of BMI g
institute. e
size was calculated as clinical sphygmomano- 23 to adult Independent s
i s
1800 with an estimated meter with appropriate- equivalent of BMI samples t test was
t c
prevalence of overweight sized cuffs, using a 27.99) or obese applied to compare y h
and obesity among stethoscope placed over (adult equivalent of the means, and the o
school-going adolescents the brachial artery pulse. BMI > 28). proportions were – o
of 20%11 with an Body mass index (BMI) compared using l
Normal BP 1
allowable error of 10%, was calculated by weight Chi square test. P 1
was defined as g
and a non-response rate in kg divided by height in value of <0.05 was .
SBP and DBP
of meter square. All less than considered 4 o
10%. It was decided to anthropometric % i
90th percentile for statistically )
cover about 10% (12 measurements and data sex, n
age, and significant. . g
schools) out of the total collection by height.
112 schools with random questionnaire were done Hypertension was Re a
selection of 6 government by two trained Medical defined as average sul T d
and 6 private schools. Social Workers and BP SBP or DBP ts a o
From each school was measured by four greater than or b l
The age of
150 students were medical interns. BP was equal to the 95th l e
adolescents varied e
selected (30 students measured 3 times in right percentile for sex, s
from 10-16 years
from each class VI to X) arm, sitting position at 0, age, and height on c
with a mean age 1
by systematic random 5 and 30 minutes and the at least three e
(SD) of 13.03 : n
sampling from the average of readings was separate occasions.
(1.43) years with t
attendance register. In taken. Average SBP or almost equal E s
case of absentees, the next DBP levels that are l
Adolescents were number of boys and
roll number was included. greater than or e Blo No.
categorized according to girls, 51.7% and od (%)
Ethical clearance was equal to the 90th v Elevate
29
their BMI using BMI 48.3% respectively. dElevate
(1.6)
SBP
obtained from percentile, but less a 82
percentile curves for Majority, 94.9% dE (4.6)
DBP
Institutional ethics than the 95th t 178
Indian boys and girls were Hindu and le(9.9)
committee and permission percentile, had e Not
13
from 5- 17 years as per 68.94% belonged d
from Principal/ elevated
1
been designated as to general category,
recommendation of E
Headmasters of the “high normal” and
Khadilkar, et al12 They 72.6% of study b lev
schools were taken prior were considered to
were classified as: subjects belonged l ate
to the study. Data be an indication of
underweight to nuclear families. o d
collection was done by heightened risk for It was observed o blo
taking assent from developing d
that 27.8% of od
adolescent students. hypertension.13 In adolescents were pre
this study, Blood p
Anthropometric overweight/ obese ssu
pressure was r
measurements viz. height, (overweight – re
measured 3 times e
weight were measured. 1 s wa
at 0, 5 and 6
Height was measured by s s
30 minutes .
stadiometer to the nearest 4 u obs
and the
centimetre without shoes. average of % r erv
Weight was measured readings was e ed
with light clothing and taken. a
am
n a
24 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
ong 16.1% school going
adolescents. Among them,
elevated SBP was found
among 1.6%, elevated
DBP among 4.5% and
both SBP and DBP in
9.9% adolescents (Table
I).
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 23

Table 2: Overweight/Obesity among students and elevated blood pressure

Nutritional status Total Children Prevalence of Elevated BP Remarks
Underweight 86 4 (4.7%)
Normal 1213 135 (11.1) X2 = 135.075
Overweight 295 65 (22.0) P = 0.000
Obese 206 85 (41.3)
Table II shows that prevalence of elevated BP Elevated blood pressure was observed significantly
increased with increase of nutritional status and there higher among overweight/obese adolescents (P=0.000)).
is significant difference of elevated BP among different As BMI and waist circumference increased, SBP and
grades of nutritional status. DBP increased and correlation was significant at 0.01
level (Table III, Fig 1 and 2).
Table 3: Correlations between BMI and blood
pressure Discussion
Variable r p value In our study, elevated blood pressure was observed
BMI and Systolic blood pressure .417 .000 among 16.1% of school going adolescents. Among
BMI and Diastolic blood pressure .332 .000 them, elevated SBP was found among 1.6%, elevated
DBP among 4.5% and both SBP and DBP in 9.9%
adolescents. The present study also revealed that
prevalence of elevated BP increased with increase of
nutritional status and there is significant difference of
elevated BP among different grades of nutritional status.
Elevated blood pressure was significantly higher among
overweight/ obese adolescents (P=0.000). As BMI
increased, SBP and DBP increased and correlation was
significant at 0.01 level. In the study by Sundar JS et al
in Chennai among 13-17year age group school children,
prevalence of adolescent hypertension was 21.5% and
one of the major determinants was found to be increased
Body mass index.14 In the study by Xi Lu et al in China
BMI is positively correlated with SBP and DBP. Being
Fig. 1: Correlation between BMI and SBP overweight or obese greatly increased the risk of
hypertension in Chinese children and adolescents.15

Conclusion

The prevalence of elevated blood pressure was

significantly higher among overweight/obese adolescents
and BMI was significantly correlated with blood
pressure. All overweight/obese adolescents should be
screened for hypertension and early intervention
measures should be taken for weight reduction and BP
control.

Conflict of Interest: NIL

Source of Funding: Siksha ‘O’ Anusandhan deemed to

Fig. 2: Correlation between BMI and DBP be University, Bhubaneswar
24 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Ethical Clearance: Ethical clearance from the 8. Sung RYT, Lam YM, Leung SSF. Blood pressure
Institutional ethical committee, IMS & SUM Hospital in Hong Kong Chinese children: correlation
was obtained. with anthropometric data. JHK Coll
Cardiol.
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of the Commissionon Ending Childhood of overweight among preschool children
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clusters in 21 regions, 1990-2010: a systematic in Indian children. Indian Pediatr. 2012;49:29-34.
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and Adolescents. U.S. Department of health and
4. Patel V, Chatterji S, Chisholm D, Ebrahim S, human services, National Institutes of Health,
Gopalakrishna G, Mathers C, et al. Chronic National Heart, Lung, and Blood Institute. www.
diseases and injuries in India. Lancet. nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf.
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14. Sundar JS, Adaikalam JMS, Parameswari S,
5. Singh AS, Mulder C, Twisk JW, van Mechelen Valarmarthi S, Kalpana S et al. (2013) Prevalence
W, Chinapaw MJ. Tracking of childhood and Determinants of Hypertension among Urban
overweight into adulthood: a systematic review of School Children in the Age Group of 13- 17
the literature. Obes Rev. 2008;9(5):474–488. Years in, Chennai, Tamilnadu. Epidemiol 3:130.
6. Chen X, Wang Y. Tracking of blood pressure doi:10.4172/2161-1165.1000130.
from childhood to adulthood: a systematic 15. Xi Lu, Peng Shi, Chun-Yan Luo, Yue-Fang
review and meta-regression analysis. Circulation. Zhou, Hui-Ting Yu, Chang-Yi Guo and Fan
2008;117(25):3171–3180. Wu. Prevalence of hypertension in overweight
7. Horne RS, Yang JS, Walter LM, et al. Elevated and obese children from a large school-based
blood pressure during sleep and wake in children population in Shanghai, China. BMC Public
with sleep-disordered breathing. Pediatrics. Health 2013; 13:24
2011;128(1):e85–e92.
DOI Number: 10.5958/0976-5506.2019.01531.6

The Effectiveness of Constraint-Induced Movement Therapy

and Placing Technique of Bobath on Upper Limb Function in
Hemiparetic Individual

Manali N. Hanphode1, G. Varadharajulu2, Suraj Kanase3

1
MPT, 2Dean, Professor, 3Associate Professor, Faculty of Physiotherapy, Krishna College of
Physiotherapy, KIMS ‘Deemed to be’ University, Karad, Maharashtra, India

ABSTRACT
Objectives: The purpose of this study was to find the the effectiveness of Constraint-Induced Movement
Therapy and Placing technique of BOBATH on upper limb function in hemiparetic individual.
Method: 44 subjects diagnosed with hemiparesis were included in this study with age group between 40-60
years. Participants with group A (22) were treated with CIMT and placing technique of bobath and group
B (22) were treated with CIMT only. Before and after the treatment protocol the subjects were assessed for
sensorimotor function by FMS, functional assessment by MAL scale and upper limb-hand co-ordination by
BBT. These outcome measures were analysed.
Result: Pre-and post treatment protocol was analysed by using Wilcoxon matched pairs test and paired t
test. Data analysis showed significance for FMS (p=0.0115) and extremely significance for BBT (p <
0.0001) and there is increase in number of subjects with value of 2.5 and 3 in group A than group B for
MAL scale.
Conclusion: CIMT combine with Placing technique of Bobath has shown good improvement on upper
limb
function in hemiparetic individuals.

Keywords: constraint-induced movement therapy, placing technique of bobath, fugl-meyer scale, motor
activity log scale, box and block test, upper limb function.
Introduction of the brain injury.3,4 There are timing abnormalities that
contribute to impairment of coordinated motor sequence
Stroke or Brain attack is the sudden loss of
which prolonged the movement times.5,6 Also, there is
neurological function caused by an interruption of the
increase co-activation of agonist and antagonists that
blood flow to the brain.1 Hemiparesis or weakness is
limits force production during voluntary movement.7,8
about 80 to 90% of all patients after stroke. It is a major
contributor to disability.2 The force which is necessary Constraint-Induced Movement Therapy is
for initiating and controlling the movement, the designed to promote increased use of the more affected
hemiparetic individuals are not able to generate it. upper extremity. The less affected hand was immobilised
The degree of weakness is depending upon the in a sling or mitten and emphasizes on intensive and
location and the size repetitive task-oriented training of the more affected
hand involved.9 This was developed by Taub et al for the
Corresponding Author: purpose of overcoming the learned non-use phenomenon
Manali Namdev Hanphode, MPT, of the affected upper extremity and achieving functional
Faculty of Physiotherapy, Krishna recovery.10 Neurophysiological basis of CIMT is that, its
Institute of Medical Sciences Deemed include overcoming learned non-use and plastic brain
to be university, re-organization.11
Karad-415110, Maharashtra, India
Phone: 9769682915, 8655562186 Placing technique of Bobath was used to teach
Email: [email protected] the subject to hold his arm against gravity in the
three
26 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 26

positions illustrated. He was asked to hold his arm at treatment in addition for the groups; Active assisted
various points throughout the range of downward exercises and active exercises, gripping exercises,
motion.12 This was developed by Berta Bobath. The strengthening exercises etc. each activity 10 repetitions.
patient has lost the normal adaptation of muscles against
gravity during movements of his limbs.13 Outcome measures:

Recovery of upper limb function is important in Fugl-Meyer scale (FMS): The pioneering work of
quality of life in hemiparetic individuals as stroke can Twitchell and Brunnstrom15,16 on motor recovery and
affect the patient’s mobility, limits daily living activities, behaviour following stroke led to the development of the
their participation in social activities and also their FMA.17 A three-point ordinal scale is used to measure
occupational activities. Paretic side resembles poor impairments of volitional movement with grades ranging
muscle strength under influence of synergistic pattern; it from 0 (item cannot be performed) to 2 (item can be
greatly affects the performance of functional activities. fully performed). Specific descriptions for performance
Because of these limitations patient became dependent. accompany individual test items. Subtest exists for UE
These all factors contribute overall low quality of function, LE function, balance, sensation, ROM, and
life.14 Hence, early interventions of the combination pain. The cumulative test score for all components
effectiveness of CIMT along with placing technique of is
Bobath on upper limb function in hemiparetic 226 with availability of specific subtest score (e.g.,
UE
individuals have been explained in detail.
maximum score is 66, LE score 34; balance score 14).

Method Motor Activity Log scale (MAL): Daily hand use was
measured using the MAL, 28 a semi-structured
Population: The subjects which willing to participate
interview relating to 30 common daily tasks and
in the study was taken. Out of 44 subjects, 32 males/12
consisting of two assessment sub-scale for rating the
females participated in this study, written consent form
affected upper extremity. The amount sub-scale
was taken. The criteria for inclusion were: age between
addresses the amount of use; the how well sub-scale
40-60 years, brunnstrom stage 2 and above. Subjects addresses the quality of movement. A six-point rating
were excluded if they had any other musculoskeletal scale is used in each case (0= no use of affected
problems such as shoulder hand syndrome, secondary extremity, 5= normal use).18
adhesive capsulitis, Subjects with visual and auditory
impairments psychological disorder. Box and Blocks test (BBT): Box and block test (BBT)
was used to measure promptness in the upper limbs and
Group A (22) received CIMT and placing technique hand coordination. In general, this test has been used
of bobath and group B (22) received CIMT only. The to assess unilateral gross manual dexterity of the upper
treatment was given for 2 weeks; 5 sessions per week, limbs. BBT verified the ability to reach for and grasp
ones a day. Post treatment assessment was taken after wooden regular hexahedrons (2.54 cm × 2.54 cm × 2.54
completion of 2 weeks. The protocol and the consent cm), and to transport them to the other side of a wooden
form were previously approved by protocol and ethical box (53.7 cm × 8.5 cm × 27.4 cm) with a separation
committee. Group A received placing technique was in the middle, releasing regular hexahedrons. The test
holding arm against gravity at various points throughout measured the number of hexahedrons transferred to the
range of motion. And CIMT was task-oriented training other side for 60 seconds.18,19
to affected upper limb and restricting use of unaffected
limb with help of mitten or glove; pick up the object, Statistical Analysis
move or slide the object, turn on or off the light switch,
turn pages of book, pull and push the door etc. Group Statistical analysis was done manually as well as
B received CIMT. Subjects were treated with using the statistic software INSTAT so as to verify the
baseline results obtained. Data was analyzed using Wilcoxon
27 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 27
matched pairs test and paired t test for within and
between the groups.
Results
1. FUGL-MEYER SCALE:
MOTOR FUNCTION:
Table No. 1: Comparison of pre-pre-and post-post score of Fugl-Meyer scale
Group Pre-Treatment Post-Treatment
Mean ± SD Mean ± SD
A 34.31 ± 7.69 54.13 ± 5.86
B 33.90 ± 6.73 49.45 ± 5.82
‘p’ 0.4434 0.0115
‘r’ 0.2595 0.1800

Analysis of pre-and post-interventional data was extremely significant within the group with p
value of <0.0001 for group A and group B. Statistics showed that post interventional data in between
the group was significant with p value of 0.0115.
MOTOR ACTIVITY LOG SCALE:

GROUP A: (AMOUNT SCALE)

Table No. 2: Comparison of pre-and post-score of MAL (AS) Group A
POST
0 1 1.5 2 2.5 3 3.5 4 4.5 5 T (%)
0 1 1 1 3 13.63%
1 1 4 3 1 9 40.90%
1.5 1 5 6 27.27%
2 2 1 1 4 18.18%
PRE 2.5
3
3.5
4
4.5
5
T 1 2 5 4 8 1 1 22
(%) 4.54 9.09 22.72 18.18 36.36 4.54 4.54

GROUP A: (HOW WELL SCALE)

Table No. 3: Comparison of pre-and post-score of MAL (HW) Group A

POST
0 1 1.5 2 2.5 3 3.5 4 4.5 5 T (%)
0 2 1 1 4 18.18%
1 1 3 3 1 8 36.36%
1.5 1 5 6 27.27%
2 2 1 1 4 18.18%
PRE 2.5
3
3.5
4
4.5
5
T 2 2 4 4 8 1 1 22
(%) 9.09 9.09 18.18 18.18 36.36 4.54 4.54
GROUP B: (AMOUNT SCALE)

Table No. 4: Comparison of pre-and post-score of MAL (AS) Group B

POST
0 1 1.5 2 2.5 3 3.5 4 4.5 5 T (%)
0 2 1 3 13.63%
1 3 6 1 10 45.45%
1.5 1 3 4 18.18%
2 1 1 2 9.09%
PRE 2.5 2 2 9.09%
3
3.5 1 1 4.54%
4
4.5
5
T 2 4 7 1 6 1 1 22
(%) 9.09 18.18 31.81 4.54 27.27 4.54 4.54

GROUP B: (HOW WELL SCALE)

Table No. 5: Comparison of pre-and post-score of MAL (HW) Group B

POST
0 1 1.5 2 2.5 3 3.5 4 4.5 5 T (%)
0 2 1 3 13.63%
1 4 4 1 9 40.90%
1.5 1 3 4 18.18%
2 1 1 1 3 13.63%
PRE 2.5 2 2 9.09%
3
3.5 1 1 4.54%
4
4.5
5
T 2 5 6 1 6 1 1 22
(%) 9.09 22.72 27.27 4.54 27.27 4.54 4.54

BOX AND BLOCK TEST:

Table No. 6: Comparison of pre-pre-and post-post box and block test between groups

Pre-Treatment Post-treatment
Group
Mean ± SD Mean ± SD
A 23.22 + 8.39 37.36 + 12.22
B 19.72 + 6.34 25.18 + 6.50
‘p’ 0.0662 < 0.0001
‘t’ 1.983 5.003
Intra group statistical analysis was carried out by Some studies have evaluated the effects of CIMT
paired t test and showed extremely significant difference combined with other treatments. Hyun Seok et al. 22
with p value <0.0001 for group A and for group B. performed CIMT combined with visual biofeedback
Statistics showed that post interventional data in between training for subacute stroke patients. Combination
the groups was extremely significant with p value of < group did not show significant improvement than VBT
0.0001. only group. Another study by Yoon et al21 performed
CIMT combined with the mirror therapy for hemiplegic
Discussion patients after stroke. Combination group showed more
improvement than CIMT only group in the fine motor
The present clinical trial was conducted to find
functions of the hemiplegic upper limb. In our study,
out the effectiveness of CIMT and placing technique
combination of CIMT and placing technique of Bobath
of Bobath on upper limb function in hemiparetic
showed significant improvement in combination group
individuals.
as here sample size was larger than previous study.
Total 44 subjects who were clinically diagnosed
The above findings were due to, CIMT shows
with hemiparesis fulfilling inclusion and exclusion
Function-induced recovery (use dependant cortical
criteria were taken in this study.
reorganization) refers to the ability of nervous system
Statistical analysis was performed by using Instat- to modify itself in response to changes in activity and
Graph pad. Among them, 24 had right sided hemiparesis environment. CIMT supports the concept of redundancy.
(Group A = 10, Group B = 14) and 20 had left sided The generation of new or redundant neuron pathways
hemiparesis (Group A = 12, Group B = 8). Out of 44 permits cortical map reorganisation and maintenance
subjects, 34 subjects had ischemic (Group A = 14, of function. This plastic brain re-organization which is
Group B = 20) and 10 subjects had haemorrhagic type of effect of CIMT in improvement of hand function.
stroke (Group A = 8, Group B = 2).
Placing technique of bobath has effect on the normal
Wilcoxon matched-pairs test used to analyse the adaptation of muscles against gravity during movement
effect of CIMT and placing technique of bobath on of limbs which improves proximal arm control. This
upper limb function on FMS within the group which is due to; functional activity is not possible unless the
showed that there was significant improvement in patient can hold his arm at shoulder in any position
upper limb sensorimotor function with (p < 0.0001) and while moving the elbow and hand independently.
in between the groups there was significant Placing technique supports the principle of Bobath
improvement with p value of 0.0115 post treatment. which is facilitation versus inhibition. The normal
postural reactions and normal patterns of movements
Intra group analysis of MAL (amount and how well) should be facilitated along with reflex inhibitory
scale showed improvement and Inter group analysis movement patterns. Stimulation of proximal key points
of MAL (amount and how well) scale score, post as a facilitation technique used in Placing.
interventional showed that there is increase in number of
subjects with value of 2.5 and 3 in group A than group So, we get independent and controlled movement
B. which improves the overall quality of gross and fine
upper limb function in daily living activities with
Some previous study has evaluated the efficacy combination of CIMT and placing technique of bobath.
of modified CIMT in hemiparetic upper limb stroke
patients. Rajkumar Yadav et al.20 performed modified Thus, it is proven that, early physical therapy
CIMT using FMA and MAL as outcome measures interventions like placing technique of bobath along
which showed significant improvement with FMA (p with CIMT hasten the prognosis and these are cost
value <0.0001) and MAL amount scale (p value 0.0007), effective.
how well scale (p value 0.0015) at end of one month
after treatment. Conclusion
Paired t test used to analyse the effect of CIMT and Based on the statistical result and interpretations it
placing technique of bobath on BBT for upper limb and was concluded that, the present study provides evidence
hand coordination within and between the group. This to support the use of placing technique of bobath with
showed there was extremely significant improvement constraint-induced movement therapy which is more
with (p < 0.0001). Previous study by Jin A Yoon et effective than constraint-induced movement therapy
al.21 performed BBT as a one outcome measure which alone on improving upper limb function in hemiparetic
showed improvement with mean and standard deviation individuals.
(21.88 ± 14.18) and (p value 0.012).
Conflict of Interest: There were no conflicts of interest 12. BERTA BOBATH, MBE, FCSP, PhD (Hon
in this study. Boston) Adult Hemiplegia: Evaluation and
Source of Funding: This study was funded by Krishna Treatment, third edition. Page no. 166
Institute of Medical Sciences Deemed to Be University, 13. BERTA BOBATH, MBE, FCSP, PhD (Hon
Karad. Boston) Adult Hemiplegia: Evaluation and
Treatment, third edition. Page no. 28,29.
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DOI Number: 10.5958/0976-5506.2019.01532.8

Effect of Manual Positioning as an Adjunct to Intercostal

Drainage tn Hydropneumothorax

Monali M. Kashyap1, Javid Hussain Sagar2, G. Varadharajulu3

1
MPT, 2Associate Professor, 3Dean, Faculty of Physiotherapy, Krishna College of
Physiotherapy, KIMS ‘Deemed to be’ University, Karad, Maharashtra, India

ABSTRACT
Objectives: The purpose of this study was to check the effect of manual positioning in supine lying, side
lying, and semi fowler’s (450)
Method: 30 subjects diagnosed with hydropneumothorax with ICD. were included in this study. These
subjects were allocated by convenient sampling method. RR, spo2, CC of all the three levels. (axillary
level,2nd intercostal space, xiphistrenum level.) Pretreatment and post treatment assessment was noted
down according to the pulse oximeter and with measurement tape. These outcome measures were analyzed.
Result: Pre and post treatment protocol was analyzed by using paired t test. Data analysis showed
extremely significance in group C for RR (p=<0.0001) spo2 (p=0.0006) CC axillary level (p=<0.0001) 2nd
intercostal space (p=<0.0001) xiphistrenum level (<0.0001).
Conclusion: this study concludes that semi-fowlers position was more improved as compared to
the two
positions.
Keywords: chest circumference, inter costal drainage,
hydropneumothorax.
Introduction pleural fluid aspiration in effusion, presence of gas-
forming organism, thoracic trauma.2 For this purpose
Hydropneumothorax is the abnormal presence
an intercostal tube draining is used to collect the fluid,
of air and fluid in the pleural space. The knowledge
blood, air, to allow the underlying lung to expand. itis a
of hydropneumothorax dates back to the days of
flexible plastic tube that is inserted through the chest
ancient Greece when the Hippocratic succession used
wall and into the pleural space from the intrathoracic
to be performed for the diagnosis. There have been
space. It is also known as a Bülau drain3.
tremendous advancements in the field of laboratory
Pathophysiology if air, fluid, or blood enters the tiny
and radiological diagnosis and therapeutic management
space between the parietal and the visceral pleurae, the
for pleural pathologies1. However, not many national
negative tendency to recoil will take over and the lung
or international literature are documented regarding
will collapse4.the patient may experience minimal
hydropneumothorax. patient seen with straight line
symptoms or significant shortness of breath.in addition
dullness, shifting dullness, splash, fullness of chest
the parietal pleurae are highly innervated with sensory
is seen. Causes iatrogenic: introduction of air during
nerves, so any change in the pleural space may be very
painful as well. Pleuritic pain is character-sized by a
Corresponding Author: sharp, stabbing pain during inspiration as the pleurae
Monali Mahendra Kashyap, move1
MPT, Faculty of Physiotherapy,
Krishna Institute of Medical Sciences
Manual Positioning
Deemed to be University,
Karad-415110, Maharashtra, India Manual positioning is prescribed to optimize
Phone: 9067244298 cardiopulmonary function and oxygen transport is
Email: [email protected] different from routine body positioning18. Positioning
stimulate normal physiological effect of gravity and
32 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 32

change on oxygen transport are priority that is being each patients was taken as per the data collection sheet.
upright and moving19. The distribution and ventilation Out of 30 subjects in group A 10 patients 8M 2F. Group
in the lungs are primarily influenced by gravity and B 10 patients 8M 2F. Group C 10 patients 6M 4F
by manual positioning. Manipulating body positioning participated in this study, All the subjects were informed
however alters both intraregional and interregional about the protocol and gave written consent before their
determinants ventilation perfusion and their matching. participation. The protocol and the consent form were
Changing a patient’s position may not seem a dramatic previously approved by protocol and ethical committee.
technique, but some action often prevents recourse
to more time consuming. Positioning is an integral Interventions: Subjects who were referred to Krishna
part of all respiratory care. Sometimes knowledge Hospital, Karad, and diagnosed as hydropneumothorax as
and technology can’t save patients complications and an adjunct with ICD. The nature of study and intervention
the stay in hospital is prolong.so, something simple were explained to the subjects and those who were
as giving the patient manual positioning like supine willing to participate were included. Before proceeding to
lying, side lying, semi-fowler. Positioning generates intervention a written consent was taken from subject. A
significant alterations in arterial oxygenation in patients brief demographic data was recorded. By using random
with unilateral lung diseases16. Change in positioning sampling method, the participants were divided into three
and the consequent change of the gravity effect, among groups by convenient sampling method.
other factors, cause change in respiratory function at In group A: Patients in this group were given supine
different intensities27. body position changes to aid in position. But before the intervention base-line values
the prevention of skin breakdown, to enhance secretion were taken. RR, SpO2, CC measurement was taken.
clearance, and to improve ventilation perfusion9 10. That is axillary level, 2nd inter costal space, and
Proper positioning is also vital for providing comfort for xiphisternum level was noted down. after that supine
patients who are bedridden or have decreased mobility position was given. treatment was given continuously
related to a medical condition or treatment. Supine is the for 2 weeks,1 session per day. Each position was
least helpful position for lung function7, 8. For ventilated maintained 2 hours in the morning and 2 hours in
patients the lateral position increases functional residual afternoon. Post treatment assessment was taken after
capacity and enhances gas exchange compared with completion of 2 weeks.in supine lying pre-intervention.
supine. Patients who are confined to bed should spend RR was 30 breaths per minute, SpO2 was 89%, Axillary
a proportion of time on their side lying well forwards level=32.5cm,2ndintercostal space=32cm, xiphisternum
so that their diaphragm is free from abdominal pressure. level=30cm. post intervention RR was 21 breaths
Compared to supine this position not only increases lung per minute, SpO2 was 90%, Axillary level=32.7,2nd
volume, but also improves gas exchange and reduces the intercostal space=33, xiphisternum level=31.
work of breathing. Airflow resistance is lower in side
lying compared to supine13. Optimizing O2 transport is In group B: Patients in this group were given side
goal of positioning and mobilization13. the purpose of lying position. That is the opposite side. But before the
this study is to throw light on the effects of various intervention base-line values were taken. RR, SpO2,
manual body positioning in patients with inter costal CC measurement was taken. That is axillary level, 2nd
drainage in hydropneumothorax. It affects the inter costal space, and xiphisternum level. Was noted
pulmonary volumes of the lung manual positioning down after that side lying position was given. treatment
reduces the collapsing of lungs. And improves the gas was continuously given for 2weeks 1 session per day.
exchange. Each position was maintained 2 hours in the morning
and 2 hours in afternoon. Post treatment assessment
Method was taken after completion of 2 weeks.in side lying pre-
intervention. respiratory rate was 23 breaths per minute,
Population: Patients diagnosed with hydropneumothorax SpO2 was 84%, Axillary level=34cm,2nd intercostal
with ICD. volunteered participate in the study were taken space=35cm, xiphisternum level=35.5cm, post
as patients. Each of the patient was screened as per full intervention RR was 22 breaths per minute, SpO2
filling the inclusion and exclusion criteria. and they were was
briefed about the study and intervention. Informed 92%, Axillary level=33.8,2nd intercostal
consent was taken from the patients. Initial through space=35.7cm,
the assessment of xiphisternum level=35.2,
In group C: Patients in this group were given semi- Chest circumference: Circumference of chest at the
fowler’s position. But before the intervention base- fullest part of the breast region. The measurement
line values were taken. RR, SpO2, CC measurement of chest was taken when patient was positioned in
was taken. That is axillary level, 2nd inter costal space, supine lying, side lying, semi-fowler position pre
and xiphisternum level. Was noted down after that and post measurement was noted down. Axillary
semi-fowler’s position was given. treatment was given level,2ndintercostal space, xiphisternum level.
continuously for 2 weeks 1 session per day. Each
position was maintained 2 hours in the morning and 2 Result
hours in afternoon. Post treatment assessment was taken
Pre and post treatment protocol was analyzed
after completion of 2 weeks.in semi-fowler’s position
by using paired t test.in group A RR not significant
pre-intervention. respiratory rate was 28 breaths per
(p=0.2813) spo2 not significant (p=0.0944) CC axillary
minute, SpO2 was 92%, Axillary level=33.5cm,2nd
intercostal space=32cm, xiphisternum level=30cm. post level significant (p=0.0087) 2 intercostal space
intervention RR was 18 breaths per minute, SpO2 nd

was significant (p=0.0414) xiphisternum level significant

96%, Axillary level=34cm,2nd intercostal space=32.3cm, (p=0.0106) in group B RR not significant (p=>0.9999)
xiphisternum level=30.2cm spo2 significant (p=0.0016) CC axillary level not
significant (p=0.1637) 2nd intercostal space not
After 2-week posttest values was taken than by
significant (p=0.7895) xiphisternum level significant
statistical analysis result was calculated.
(p=0.0212) in group C RR extremely significant
Measurement Procedure: Respiratory rate is act of (p=<0.0001) spo2 extremely significant (p=0.0008) CC
breathing, the normal RR is 16-20 breath per min. When axillary level extremely significant (p=<0.0001) 2nd
patient was given manual positioned in supine lying, intercostal space extremely significant (p=<0.0001)
side lying, semi-fowler in intensive care unit the RR xiphisternum level extremely significant (p=<0.0001)
was noted down pre and post treatment according to the Statistical analysis: The data was entered into
pulse oximetry and was checked by the therapist. Microsoft office excels 2007 and analyzed using instat
software. Descriptive statistics were used to analyze for
Peripheral oxygen saturation: It is an estimate of the
demographic data: Pre and post treatment protocol was
amount of oxygen in the blood. More specifically it is
analyzed by using paired t test.
the percentage of oxygenated haemoglobin
(haemoglobin containing oxygen) compared to the As per the inclusion criteria 30 subjects were
amount of haemoglobin in the blood (oxygenated and included in the study. During 2 weeks of protocol
non- oxygenated haemoglobin). when patient was program 10 subjects in group A where given supine
positioned in supine lying, side lying, semi-fowler in position .10 subjects group B where given side lying
intensive care unit the SpO2 was noted down pre and position. 10 subjects in group C where given semi-
post treatment by pulse oximetry. fowler position. Pre and post analysis were done for 30
subjects. In Table.1 Table.2 Table.3
Table 1: Pre and Post Interpretation of Group A
PRE TREATMENT POST TREATMENT
GROUP A INTERPRETATION
Mean ± SD Mean ± SD ‘t’ value ‘p’ value
RR 24.5 ± 3.171 22.9 ± 1.912 1.199 0.2613 Not significant
SPO2 87.7 ± 3.831 90.1 ± 2.685 1.869 0.0944 Not significant
CC
34.15 ± 2.925 33.44 ± 2.717 3.339 0.0087 Very significant
(AXILLAY LEVEL)
CC (2ND
INTERCOSTAL 34.99 ± 3.044 34.22 ± 2.834 2.377 0.0414 Significant
SPACE)
CC
(XIPPISTERNAL 34.85 ± 3.408 34.14 ± 3.157 3.215 0.0106 Significant
LEVEL)
We studied three parameters among that axillary level P value was 0.0087 and 2nd intercostal space P value was
0.0414. xiphisternum P value was 0.0106. shows statistically significant except all other variables had no statistical
significance

Table 2: Pre and Post Interpretation of Group B

PRE TREATMENT POST TREATMENT
GROUPB INTERPRETATION
Mean ± SD Mean ± SD ‘t’ value ‘p’ value
RR 23.9 ± 2.961 23.9 ± 3.107 0.000 >0.9999 NOT SIGNIFICANT
SPO2 87.3 ± 3.713 92.1 ± 2.079 4.431 0.0016 VERY SIGNIFICANT
CC (AXILLARY
36.35 ± 2.729 35.95 ± 2.689 1.517 0.1637 NOT SIGNIFICANT
LEVEL)
CC(2ND
INTERCOSTAL 36.11 ± 2.786 36.07 ± 2.704 0.2750 0.7895 NOT SIGNIFICANT
SPACE)
CC (XIPPISTERNAL
36.58 ± 3.365 36.14 ± 3.440 2.787 0.0212 SIGNIFICANT
LEVEL)

We studied three parameters among that xiphisternum P value was 0. 0212.shows statistically significant except
all other variables had no statistical significance.

Table 3: Pre and Post Interpretation of Group B

PRE TREATMENT POST TREATMENT
GROUP INTERPRETATION
Mean ± SD Mean ± SD ‘t’ value ‘p’value
EXTREMLY
RR 26.4 ± 2.547 19.4 ± 2.366 7.000 <0.0001
SIGNIFICANT
EXTREMLY
SPO2 89.5 ± 3.440 95.7 ± 2.669 5.207 0.OOO6
SIGNIFICANT
CC (AXILLARY EXTREMLY
34.16 ± 2.348 33.3 ± 2.263 8.777 <0.0001
LEVEL) SIGNIFICANT
CC(2ND
EXTREMLY
INTERCOSTAL 35.06 ± 2.875 31.55 ± 2.518 11.296 <0.0001
SIGNIFICANT
SPACE)
CC (XIPPISTERNAL EXTREMELY
34.86 ± 3.625 32.34 ± 3.220 6.978 <0.0001
LEVEL) SIGNIFICANT
We studied three parameters among that respiratorythe patients and drainage was required for longer than 30
P value was <0.0001. SPO2 P value was 0.0006 and. days. This is usually the case seen in practice where the
axillary level P value was <0.0001. 2nd intercostal space
tube remains for longer time draining some amount of
P value was <0.0001 and xiphisternum p value was fluid due to underlying TB and most of these patients
<0.0001 which shows statistically significant. had bronchopleural fistula by prolonged air leak in
ICD.but there are not such cases documented on effects
Discussion of manual position in patients with hydropneumothorax
with ICD. the principal goal of positioning is to optimize
Hydropneumothorax has been common entity in this proper oxygen transport, to maintain RR, and CC. Our
country. However, only isolated case reports have been previous study examined the effect of positioning on
documented on hydropneumothorax and there has been oxygenation in patients with unilateral pleural
a dearth of large case studies26.ICD was inserted in effusions23.in this study when patients are given
all positioning with ICD that is three positions are given.
Ventilation and perfusion matching
and gas exchange can be theoretically augmented in Source of Funding: This study was funded by Krishna
the supine position by an increase in cardiac output. Institute of Medical sciences Deemed to Be University,
The SpO2 remains president even if the patient is in Karad.
supine position and is supported by various studies. In
all the three-position comparing the lung function in
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semi-fowlers position could be a therapeutic adjunct 1. Emerson CP (Charles P. Pneumothorax: A
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is frequently instituted for both medical and surgical 1903]; 1903. p. 466. Available from: http://www.
patients.in patients after surgery arterial oxygen tensions archive.org/details/pneumothoraxhist00emer. [Last
were greater in the lateral position.in this position cited on 2013 Oct 17].
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2. 3Clarke, Christopher; Dux, Anthony (2017).
and
2nd intercostal space is not significant, xiphisternum Chest X-rays for Medical Students. John Wiley &
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to that of semi-fowlers position, there is two important 3. Noppen, M. (2002). “Manual Aspiration versus
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gravity dependent the vertical hydrostatic gradient is Spontaneous Pneumothorax: A Multicenter,
smaller in the lateral that in semi-fowlers position19.in Prospective, Randomized Pilot Study”. American
regard to ventilation the dependent diaphragm is pushed Journal of Respiratory and Critical Care
higher into chest by abdominal contents compared with Medicine.
the nondependent lung diaphragm thus side lying can
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fowlers position maximizes lung volumes and capacities
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in semi- fowlers position the FRC and tidal volume is 8. Hess D, Agarwal NN, Myers CL: Positioning,
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9. Clauss RH, Scalabrini BY, Ray JF, Reed GE:
adjunct with ICD.
Effects of changing body position upon improved
So, this study supports the alternate hypothesis ventilation perfusion relationships. Circulation
1968, 37:214–217.
Conflict of Interest: There were no conflicts of interest
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ClaramontR,Ibaneze P, Bergada J. The effects
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DOI Number: 10.5958/0976-5506.2019.01533.X

Effect of Motor Control Training on Isolated Lumbar

Stabilizer and Core Muscle Training in Chronic Low Back
Pain Patients

Namrata P. Mane1, G. Varadharajulu2, Sandeep Shinde3

1
Physiotherapist, 2Dean, Faculty of Physiotherapy, 3Assistant Professor, Krishna College of
Physiotherapy, KIMS ‘Deemed to be’ university, Karad, Maharashtra, India.

ABSTRACT
Background: The segmental stability of vertebrae of lumbar spine is maintained by contraction of the
transverse abdominis, multifidus. Impaired functioning of the deep stabilizers may lead to poor segmental
stabilization which inclines to injury. In order to provide spinal stability it has been projected as a key
component in controlling of chronic low back pain exercise programs aimed at augmenting strength,
retraining these muscles.
Objectives: Present study was undertaken to compare the effect of motor control training on isolated
lumbar
stabilizer and core muscle training in chronic low back pain patients.
Method: A experimental study was conducted in and around hospitals of karad, following a simple random
sampling technique on a sample size of 66. The participants were divided into 2 groups. Group A was
given HMP, TENS, Motor Control Training and Group B was given HMP, TENS, Core Muscle
Training.All outcome measure were assessed before starting and at the end of treatment. The data were
analyzed using Instat Software.
Result: On comparing post treatment scores, there was no statistically significant difference in p values for
NPRS and MODQ but was statistically significant difference in p values for Electromyography of
transverse abdominis, multifidus.
Conclusion: The study concluded that Motor Control Training was found more effective than Core Muscle
Training for patients with chronic low back pain.

Keywords: Chronic low back pain, Motor Control Training, Core Muscle Training,
Electromyography,
Transverse Abdominis,
Multifidus.

Introduction

Low back pain is usually defined as pain, muscle

tension, or stiffness localized below the costal margin
and above the inferior gluteal fold, with or without leg
pain1. Low back pain is one of the major health problem,
mostly accompanied with expensive care, disability and
Corresponding Author: absenteeism2. Nearly 10-20% patients suffering from
Dr. Namrata P. Mane low back pain develop chronic low back pain (LBP
Physiotherapist, Faculty of Physiotherapy, more than 3 months)3. About 70% world’s population
Krishna Institute of Medical Sciences will have low back pain at least once in their life.
Deemed to be university,
Karad-415110, Maharashtra, India The segmental stability of lumbar vertebrae is
Phone: 8805749477 maintained by contraction of transverse abdominis,
Email: [email protected] multifidus4. Studies on individuals with LBP shown lack
38 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 38

control of deep trunk muscles5. All abdominal muscles The exercises were developed by Richardson and
control the stability of spine, but some researchers colleagues which play a major role in stabilizing the
focused on function of deep muscles6. deeper muscles. Motor control exercises help to re
Generation of force against lumbar lordosis -instruct the optimal control of the spine . Based on the
is
because of pressure created by visceral cavity anterior 13

to spine, results in increase the structural spine stability principle that individual with LBP have a lack of control
for a various posture, movements7. When lumbar of the trunk muscles the motor control exercise has
spine positioned neutral, abdominal bracing maneuver been developed. The motor learning approach is used to
produces contraction of antagonist muscle which retrain the optimum control and coordination of spine5.
increases spine stability8.
Increased activity of superficial trunk muscles in
Osteoarthritis (OA) a common disease of aged patients with recurrent LBP delays activation of deep
population and one of the leading causes of disability. muscles14. In individuals with chronic low back pain and
Incidence of knee OA is rising by increasing average
a delay of the anticipatory postural adjustments of some
age of general population. Age, weight, trauma to joint
trunk muscles in line,studies reported an over -activation
due to repetiting movements in particular squatting and
of superficial para -vertebral muscles15.
kneeling are common risk factors of knee OA. Several
factors including cytokines, leptin, and mechanical There were very less studies accessible in relation
forces are pathogenic factors of knee OA. In patients with the short term effect of motor control exercises
with knee pain attribution of pain to knee OA should and core muscle training on subjects with chronic low
be considered with caution. Since a proportion of knee back pain. This study resulted in better planning and
OA are asymptomatic and in a number of patients treatment of chronic low back pain. So there was need to
identification of knee OA is not possible due to low study effect of motor control training on isolated lumbar
sensitivity of radiographic examination. In this review stabilizer and core muscle training in chronic low back
data presented in regard to prevalence, pathogenesis, pain patients.
risk factors.
Materials and Method
Keywords: Knee, Osteoarthritis, Pathogenesis,
Prevalence A experimental study was conducted in and around
Increased superficial back muscle activity may result hospitals of karad, following a simple random sampling
in limitation of tensile forces, motion of painful technique on a sample size of 66. The participants were
structures in back9. Multifidus repossession from divided into 2 groups. The study protocol was started
inhibition related with LBP does not resolve pain, after being approved by institutional ethical committee
disability10. The cross- sectional area of multifidus is of Krishna Institute of Medical Sciences Deemed To
decreased in people with acute unilateral LBP from Be University, Karad. Subjects were selected according
Ultrasound measurement11. Impaired functioning of the to inclusion criteria. Written informed consent was
deep stabilizers may lead to poor segmental taken and the whole study was explained to them. Each
stabilization12. subject was assessed for muscle activity, intensity of
pain and activity limitation by using Electromyography,
A major trend in rehabilitation is core strengthening. Numeric Pain Rating Scale and Modified Oswestry
To maintain functional stability, the muscular control disability Questionnaire. The equipments used were
required around lumbar spine. It is a form of
(1)Electromyography machine, (2)Transcutaneous
rehabilitation used as preventive regimen, performance
electrical nerve stimulation, (3)Hot moist pack.
-enhancing program for lumbar spine injuries. In
Inclusion criteria was as follows: (1)Subjects with
training for prevention of injury as well as for treatment
chronic low back pain (low back pain more than 3
for various musculoskeletal conditions principle of
months). (2) Subjects with their pain intensity less than
core stability has been recognized widely12.
39 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 39
or equal to 5 on NPRS. (3)Age group: 30-60 years.
Exclusion criteria
was as follows: (1)Subjects with red flag which suggests Table 2: Comparison of pre- pre and post- post
serious spinal pathology. (2)Subjects with neurological NPRS score
deficits. (3)Pregnancy. (4)Any past history of fracture in
Pre-intervention Post-intervention
proximal femur or pelvis. (5)Previous medical history Groups
Mean ± SD Mean ± SD
of vertebral fracture,congenital spine disorders. (6)Any A 4.09 ± 1.04 0.90 ± 0.76
recent surgery for LBP. (7)Subjects who are unable to B 4.00 ± 0.93 0.90 ± 0.84
go to prone position. P Value 0.71 0.99
Group A: Motor control training5, HMP and TENS. The table shows comparison of mean and standard
deviation of NPRS scores in Group A and B. Pre and
First week: 8 reps: (1)Activation of transversus
post intervention shows that there is no significant
abdominis. (2)Activation of multifidus difference in the NPRS scores.

Second week: 15 reps, 5-10 sec hold: (1)Strengthening MODQ- Intra Group comparison using Paired t-
of test.
transversus abdominis. (2)Strengthening of Multifidus.

Group B: Core muscle training8,12,22,23, HMP and TENS.

Table 3: Comparison of pre and post MODQ score
First week: 8 reps: (1)Abdominal hollowing. (2) Pre- Post-
Abdominal hollowing with leg lifts. (3)Pelvic tilt. (4) Groups intervention intervention P Value
Pelvic bridging. Mean ± SD Mean ± SD
A 30.48 ± 10.92 2.78 ± 2.95 <0.0001
Second week: 15 reps, 5-10 sec hold: (1) Fall out. (2) B 24.72 ± 11.64 3.39 ± 3.58 <0.0001
Modified crunch. (3)Cat stretch. (4)Back extension.
In Group A, the mean MODQ score on pre and post
All outcome measure were assessed before starting intervention was 30.48 ± 10.92 and 2.78 ± 2.95. P value
<0.0001.
and at the end of treatment.
In Group B, the mean MODQ score on pre and post
Result intervention was 24.72 ± 11.64 and 3.39 ± 3.58. P value
<0.0001.
NPRS- Intra Group comparison using Paired t- test.
MODQ- Inter group comparison using unpaired t- test
Table 1: Comparison of pre and post NPRS score
Table 4: Comparison of pre- pre and post- post
Pre- Post- MODQ score
Groups intervention intervention P Value Pre- intervention Post- intervention
Groups
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
A 4.09 ± 1.04 0.90 ± 0.76 <0.0001 A 30.48 ± 10.92 2.78 ± 2.95
B 24.72 ± 11.64 3.39 ± 3.58
B 4.00 ± 0.93 0.90 ± 0.84 <0.0001
P Value 0.04 0.45
In Group A, the mean NPRS score on pre and post
intervention was 4.09 ± 1.04 and 0.90 ± 0.76. P The table shows comparison of mean and standard
value deviation of MODQ scores in Group A and B. Pre and
<0.0001. post intervention shows that there is no significant
In Group B, the mean NPRS score on pre and post difference in the MODQ scores.
intervention was 4.00 ± 0.93 and 0.90 ± 0.84. P Electromyography- Intra Group comparison using
value
Paired t- test
<0.0001.

NPRS- Inter group comparison using unpaired t-

test
Table 5: Comparison of pre and post Electromyography score
Pre- intervention Post- intervention
Electromyography Groups P Value
Mean ± SD Mean ± SD
Right Transverse A 231.55 ± 107.29 512.06 ± 136.29 <0.0001
Abdominis B 244.27 ± 115.17 430.88 ±165.67 <0.0001
Left Transverse A 238.91 ± 123.18 545.30 ± 133.28 <0.0001
Abdominis B 255.94 ± 117.69 425.06 ±165.61 <0.0001
A 248.21 ± 94.06 539.18 ± 131.16 <0.0001
Right Multifidus
B 274.09 ± 121.15 413.27 ±153.10 <0.0001
A 306.52 ± 172.95 548.42 ± 161.99 <0.0001
Left Multifidus
B 307.06 ± 138.31 445.21 ±149.01 <0.0001

With Electromyography (Right Transverse Abdominis) score, P value <0.0001 shows that there was significant
difference in pre- post intervention scores, in both Group A and B.
With Electromyography (Left Transverse Abdominis) score, P value <0.0001 shows that there was significant
difference in pre- post intervention scores, in both Group A and B.
With Electromyography (Right Multifidus) score, P value <0.0001 shows that there was significant difference in
pre- post intervention scores, in both Group A and B.
With Electromyography (Left Multifidus) score, P value <0.0001 shows that there was significant difference in
pre- post intervention scores, in both Group A and B.
Electromyography- Inter group comparison using unpaired t- test

Table 6: Comparison of pre- pre and post- post Electromyography score

Pre- intervention Post- intervention
Electromyography Groups
Mean ± SD Mean ± SD
A 231.55 ± 107.29 512.06 ± 136.29
Right Transverse Abdominis B 244.27 ± 115.17 430.88 ±165.67
P Value 0.64 0.03
A 238.91 ± 123.18 545.30 ± 133.28
Left Transverse Abdominis B 255.94 ± 117.69 425.06 ±165.61
P Value 0.56 0.00
A 248.21 ± 94.06 539.18 ± 131.16
Right Multifidus B 274.09 ± 121.15 413.27 ±153.10
P Value 0.33 0.00
A 306.52 ± 172.95 548.42 ± 161.99
Left Multifidus B 307.06 ± 138.31 445.21 ±149.01
P Value 0.98 0.00
With (Right Transverse Abdominis) score, p value With (Right Multifidus) score, p value less than 0.05
less than 0.05 shows that there was significant difference shows that there was significant difference in the post
in the post intervention scores of Group A and B. intervention scores of Group A and B.
With (Left Transverse Abdominis) score, p value With (Left Multifidus) score, p value less than 0.05
less than 0.05 shows that there was significant difference shows that there was significant difference in the post
in the post intervention scores of Group A and B. intervention scores of Group A and B.
Discussion periodic assessment of outcome measures, Needle
Electromyography and large sample size can also be
The aim of this study was to determine effect of
taken into consideration.
motor control training on isolated lumbar stabilizer and
core muscle training in chronic low back pain patients. Ethical Clearance: Ethical clearance was taken from
This study was experimental study with Group A institutional committee of Krishna institute of medical
subjects were guided to perform motor control exercises science, deemed University, Karad.
and Group B performed core stabilization exercises.
Source of Funding: Source of funding is Krishna
We found that there is reduction in pain, disability institute of medical sciences deemed University, Karad.
and also good improvement in muscle activity. The pain
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Enterprise Gamification: A Motivational Drive at Workplace

P. S. Buvaneswari1, M S Swetha2
1
Assistant Professor of Commerce, 2Research Scholar, Dept of Commerce, University of Madras,
Chennai

ABSTRACT
Gamification, a strategy derived from game design for a non-game environment for specific cause, is the
application of elements of game playing to encourage engagement with a product or service. This strategy
widely taps the employees’ curiosity quotient and it helps in solving huge crises in simple manner.
Gamification is thus transforming business models by creating new ways to broaden relationships, making
longer-term engagement, and driving customer and employee loyalty. Globally, the concept of
gamification is widely adopted in various fields such as marketing, education, medical, human resources
and real estate business. Almost every enterprise had tried this concept either for employee management or
client management. However in India it is still in its nascent stage and there is a lot of scope to understand
the application of gamification in the Indian context. This study would help in understanding the role of
gamification as a motivator in the work place with special reference to millennial employees in Chennai
which is one of the “IT Hubs” in India. The present study attempted to investigate the perception of the
employees on Enterprise Gamification and its impact on employee motivation. The findings of the study
reveal that gamification is a vital tool in keeping the millennial employees motivated.

Keywords: Perception, Enterprise Gamification, Millennials,

Motivation

Introduction employees and employers. The first key issues resolved

through gamification are communication among
Gamification is the application of typical elements
employees. For instance, the communication goals can
of game playing (e.g. point scoring, competition with
be specified for each employee and they can be rated
others, and rules of play) to other areas of activity,
in meeting these goals (during customer interactions
typically as an online marketing technique to encourage
or communications within teams) per week and those
engagement with a product or service. Gamification is
communicating well or scoring high can be rewarded.
a strategy derived from game design for a non-game
Secondly, Gamification can find a prominent role in
environment for specific cause. It invokes new solution
measuring productivity and performance. A performance
to many problems in business. Its techniques are
reviewing tool (framed under Gamification) can keep
intended to influence people’s natural desires for
track of the specific employees’ performance over a long
socializing, learning, mastery, competition,
period of time. It also helps in training and boosting
achievement, status and self-expressions as game or
work culture.
play. Gamification is thus transforming business models
by creating new ways to broaden relationships, making
longer-term engagement, and driving customer and Review of Literature
employee loyalty. Gamification can potentially Enterprise Gamification is not just a mechanism
resolve the basic issues encircling that makes workplace more enjoyable. It drives
tangible, hard business benefits and is a powerful tool
in engaging employees to achieve successful digital
Corresponding Author: transformation1. Organizations are now more compelled
Dr P S Buvaneswari to ride gamification to bring about a radical change in
Assistant Professor of Commerce, employee, vendor, and customer experience. Similar to
University of Madras, Chennai-600005 several evidences they had also stated that in the decade
to come, several emerging technologies, including
Mobile: 9444190128
gesture
Email: [email protected]
44 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 44

control, head-mounted displays and augmented reality employee perception, it is essential to assess employees
will mature2.In addition organizations have introduced psychological needs, clarity in communicating about
legal and ethical considerations, and have also provided gamification to employees before implementation is
pointers to other resources to continue the journey in very important, implementing gamification in relation
designing gamification that works3. It is cautioned that to the psychological needs assessment, assessing and
the user engagement in enterprise gamified system is a adjusting gamification if appropriate14.Gamification
complex which contains many aspects4. Gamification implementation thus helps in understanding the behavior
at work has been described as the engagement through of the employees and the dynamics of stress
innovative interactions, besides the production of management for the same15.
competitive knowledge5.A well designed gamification
has had a powerful impact on improving the intrinsic
Background of the study
motivation of the employees within the organizations.
Gartner Inc had discussed about the “sweet spot” where Globally, gamification concept is widely spread in
many companies fail to understand it while designing a various fields such as marketing, education, medical,
gamified application. The sweet spot refers to a situation human resources and real estate business. Almost every
where in the business objective and player objective if enterprise had tried this concept either for employee
overlaps and the player will automatically get motivated management or client management. However in
in reaching the goal6.Deloitte Leadership academy had a India it is still in its nascent stage and there is a lot of
gamified application, an online program for training its scope to understand the application of gamification in
own employees as well as its clients. It also emphasized the Indian context. Secondly, millennial employees
that those executives who are interested in implementing have penetrated in the working environments who are
this popular new tool should think of gamification generally technology and game lovers. Consequently,
as a business improvement initiative and start asking HR brains have adopted gamification as a magical
business-related questions such as details about business wand to solve problems even though it is an expensive
goals, target audience and the method of tracking the
strategy. The transformation in workplace through new
success7. Gamification advocates increased engagement
trends and strategy is inevitable with a contradicting
as one of the primary benefits of the approach. Students
and a challenging phase inbuilt in the system especially
play online games for hours and gamification aim to
in countries like India. In India, the workforce mostly
tap into that same deep and persistent motivation 8.
comprises of millennials and within 2020 it will
Gamification is considered as design principle that
comprise of three different generation cohorts, Hence,
helps in changing the employees and customer’s
an understanding of the gamification and its preference
behavior, which increases the employee engagement9.
is very essential especially in Chennai which is one of
The gamification can be designed based on its six user
the “IT Hubs” in India . The present study attempts to
types such as Philanthropists, Socializers, Achievers,
investigate the perception of the employees on
Freespirits, Players and Disruptors. These types of users
get motivated for different reasons and this framework Enterprise Gamification and its impact on employee
of six user is called as Hexad framework10.While motivation.
framing gamification strategies for GenY employees
it is essential that there must be personalization and Objectives of the Study
should be relevant to their work in addition to creating
z To identify the perception of millennial employees
a meaningful expirence11. A successful gamification
on Enterprise gamification.
tool will lead to the stronger relationship between
employer and employee to a new level. It is based on z To investigate on the influence of certain
feedback, recognition, status and self-fulfillment which demographic factors in the perception of the
go beyond frames of wages and labor contract in a employees on Enterprise gamification.
workplace12.A caution note for strategy makers is that a
z To explore the impact of Enterprise gamification on
wrong gamification might create a set of false incentives
the employee motivation.
and can ruin motivation. Therefore implementation
of the strategy requires prior research, which is a cost
consuming process13.It is essential to follow a five Materials and Method
step process. The Management should gain a
Methodology of a research is a structural framework
positive
for any research paper which is a combination of
material collected and methods used in a particular Perception of the Employees on Gamification: The
research paper. Descriptive research was designed for data on the perception of the employees on gamification
the study and opportunity sampling was used to select were collected and analysed using descriptive statistics
the respondents. The data was collected through a and is presented Table 2.The study revealed that most
structured questionnaire from 156 millennial employees of the respondents perceive that social media should
from various organizations such as Amazon, Accenture, play an active role in enhancing the usage of Enterprise
Cognizant, Delloitte, Ernst Young, Oracle, ICICI, gamification (mean 4.11).The employees opined that the
RBS, Zoho, HCL, Vodafone, Infosys, Wipro, TCS, and gamification strategy should have built in challenges and
Goldman Sachs. The data collected was coded in SPSS
competition in its process (4.04).
20.0 version, and then tested for Cronbach’s Alpha
Reliability (0.8503) which ensured data reliability. Table 2: Employees perception on Gamification
KMO test for sampling adequacy (81%) showed that
the sample size was adequate. Statistical tools such as Particulars Mean Ranking
descriptive Statistics, Chi-square and Regression were I enjoy seeing my name in the
3.87 6
used to analyse the data collected. scoreboard
Gamification process should have
Results & Discussion different levels to explore the 3.95 5
talents
Demographic Profile of the Respondents: Table Rewards in gamification are
1 reveals that out of 156 respondents, 49% of the considered significant for 3.86 7
respondents were male and 51% female; 58% of the performance
respondents were team members and a minimum of I Prefer for collecting virtual/
4.00 3
11% were managers, 82 %were graduates, and 4.5% online badges
are professionals; 76.3% of the respondents were with Points should be awarded for
3.94 4
less than 5 years of work experienceand5.8% with more different activities in gamification
than 10 years of experience. Preference for built in challenges
& competition in the gamification 4.04 2
Table1: Demographic profile process
Percentage Community links with social
Category Option Respondents 4.11 1
(%) media should play an active role
Male 77 49 Source: Value Computed from primary data
Gender The employees prefer badges (4.00), Points (3.94),
Female 79 51
and names in the scoreboard (3.87) as rewards fortheir
Team
90 58 work in the gamification process. They also perceived that
Member
gamification process should have different levels to explore
Designation Team Leader 18 11
their talents (3.95). It can be inferred that the respondents
Manager 18 11 agreed that communities linked with social media should
Executive 30 20 play an active role in the gamification process.
Diploma 9 5.8
Bachelor’s Demographic Factors and Perception on Enterprise
Highest 128 82 Gamification as a Motivational Drive: The association
Degree
Educational between certain demographic variables and the
Qualification Master’s
12 7.7 perception of the respondents on Enterprise
Degree
Professionals 7 4.5 Gamification were tested using chi-square analysis.
0-5 119 76.3 H0: There is no association between demographic factors
Experience
6 -10 28 17.9 and perception on gamification as a motivational drive
(in years)
Above 10 9 5.8
H1 : There is association between demographic
Source: Primary Data factors
and perception on gamification as a motivational drive
Table 3: Pearson Chi Square and the perception on enterprise gamification. Those
Chi square value employees from different educational qualification have
Demographic had different opinion on the enterprise gamification.
Gamification–Motivational
variables On the whole the association between perceptions on
Drive
Gender 0.002* gamification with demographic factors was stronger
with gender, experience, and occupation whereas it was
Experience 0.000*
weaker with educational factor.
Occupation 0.003*
Education 0.304 Impact of Gamification in motivating the Millennial
*significance at 5 % level employees
Dependent variable: Motivation, Independent variable:
The analysis (Table 3) showed a significant
Gamification
association between Gender, Experience and Occupation
on the perception that gamification is a motivational Multiple R value: 0.758, R square value: 0.572, F
drive. There is no association between Education and the value: 208.555, P value: 000.00
perception on enterprise gamification as motivational
Table 4, provides the R and R2 values. The R value
drive. The employees with different work experience
represents the simple correlation and is 0.758 (the “R”
had same kind of perception towards enterprise
Column), which indicates a high degree of correlation.
gamification. Occupation of the employees had
The R2 value (the “R Square” column) indicates how
association with the perception on enterprise
much of the total variation in the dependent variable,
gamification especially when enterprise gamification
Intrinsic Motivation can be explained by the
challenges people’s skills. Ultimately there is no
independent variable Gamification which is very large in
association between education
this case.

Table 4: Model Summary(b)

Adjusted Std. Error of Change Statistics

Model R R2
R 2 the Estimate R Change
2
df1 df2 Sig. F
1 .758(a) .575 .572 2.65781 .575 1 154 .000

(a) Predictors: (constant), Gamification

(b) Dependent Variable:Motivation

The multiple correlation coefficient is 0.758 and it measures the degree of relationship between the actual values
and the predicted values. This coefficient value of 0.758 indicates that the relationship between (Predictors
Constant) Gamificationand Motivation is strong and positive.

Table 5: ANOVA(b)
Model Sum of Squares Df Mean Square F Sig.
1 Regression 1473.225 1 1473.225 208.555 .000(a)
Residual 1087.852 154 7.064
Total 2561.077 155

a. Predictors: (Constant), Gamification

b. Dependent Variable: Intrinsic Motivation

From the Table 5, it can be seen that the p value .000 , which is less than 0.05, indicating that, the regression
model significantly predicts the outcome variable (i.e., it is a good fit for the data).
Table 6: Coefficients(a)
Unstandardized Standardized 95% Confidence Collinearity
T Sig.
Model Coefficients Coefficients Interval for B Statistics
B Std. Lower Upper
Beta Tolerance VIF
Error Bound Bound
(Constant) 3.445 1.035 3.328 .001 1.400 5.490
1
Gamification .459 .032 .758 14.441 .000 .396 .522 1.000 1.000

a. Dependent Variable: Motivation

The coefficient of determination R-square measures tool that acts as a motivator and helps in tapping the
the goodness of fit of the estimated Sample Regression employees’ curiosity quotient. Future researches can
Plane (SRP) in terms of the proportion of the variation correlate a study between gamifications as a stressor or
in the dependent variables explained by the fitted sample a motivator and also on its application in other areas of
regression equation. Thus, the value of R square is 0.572 management.
which simply means that about 57.2% of the variation
in Gamification as Motivator is explained by the Conflict of Interest: There is no conflict of Interest
estimated SRP that uses the gamification as a motivation in
independent variable and R square value is significant at this paper
the 5% level. Source of Funding: Self
The multiple regression equation is Ethical Clearance: This is the independent work of
MOTIVATION = 3.445+ the authors. We have not published this article with any
other publisher.
0.459(Gamification)
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DOI Number: 10.5958/0976-5506.2019.01535.3

Design and Implementation of Performance Improved Medical

Signal Filters with and without Multiplier

P.Saravanan1, B. Latha2, K. Bhoopathy Bagan3

Associate Professor, Department of Electronics and Communication Engineering, 2Prof &
1

Head, The Department of Computer Science & Engineering, Sri Sai Ram Engineering college,
3
Professor, The Department of Electronics, Madras Institute of Technology, Chennai,
India

ABSTRACT
The digital filter can be done professionally with the compact area and reduced power with simplified
multiplication arithmetic. More than Decades of years Computer aided analysis of ECG signal is getting
with incredible quantity of work being carried out in the earth. This paper is a small work on our part in that
track. ECG Electrocardiogram signal is most comely known familiar and used medical signal, the ECG
signal is very responsive in nature, and still if small noise combined with actual signal the different
properties of the signal changes, Data ruined with noise must either filtered or eliminated, filtering is
important issue for design thought of real time health care process. This work presents a better FIR filter
which can be designed in VLSI technique, with or without multiplier and has less power and area
improvement.

Keywords: FIR filter design; ARM processor; Multiplier;

ECG;
Introduction speed, blood stress, oxygen infiltration levels, blood
glucose, nerve transmission, brain movement and so
In signal processing, the filter functions to remove
forth. Usually in the past, such observations are taken
the noise from the signal like random noise and also to
at clearly stated points in time and indicated in patient’s
extract the necessary parts of the signal like components
chart. Doctors in fact observe a smaller amount than one
within a precise range of frequency (Quan et
percent of these values as they make their round and
al.,
treatment are prepared based upon this chart readings
2009)1The design of the filters for specific application
includes the coefficient calculation according to various Bio-medical signal processing includes the study
criteria including sampling frequency, pass band and of these observations to offer helpful message upon
stop band frequency, filter order etc. which doctors can make conclusions. Engineers are
finding new techniques to prepare these signals by
In future, the mobile phones and portable computing
means of a range of mathematical formulae and sets of
systems are anticipated to offer increased services, faster
computer commands. Functioning with conventional
data rates and higher processing speeds at reduced
bio-measurement tools, the signals can be figured out
power dissipation levels. This delivers us with an
by software-commands and provides the doctors , idea
inspiration to explore new methods in low-
about what happening or viewable at present. By using
complexity design of high-performance digital signal
more fancy (or smart) means to carefully study what
processing blocks which operate at lower power levels.
bodies are saying, we can possibly decide the state of
Semiconductor technology today provides
a patient’s health through equipments which will not
unprecedented level of device integration where several
require cutting into the body.
orders of millions of transistors can be packaged in a
single chip using the state-of-the-art. The number is
expected to grow steadily for many years. Background
An extensive literature review was carried out on
Human bodies are continuously provides messages existing digital filters model and the method that are
about fitness. This messages may be observed through used for enhancing the performance of the digital filters.
body-structure-related devices that evaluate heart
50 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 50

Kucic et al.,(2001)2suggested a floating-gate to execute every single diverse sort of channels like low-
technology based on adaptive filter which can be pass, high-pass, band-pass, symmetric indent, all-pass,
programmed. The author has carried out a basic review low-pass score and high-pass indent. The amalgamation
on floating-gate techniques and how this technique is of the general biquad is completed withnovelty by
programmed into adaptive filter circuits. The author has summoning the relationship with direct-frame advanced
proposed a program filter method that can extend the filter structures. The unique instance of all-pass digital
capacity of the function and circuits. Furthermore, the filter acknowledgment got from the proposed global
author has demonstrated to expand our programmable filter needs extra equipment for understanding the feed
channels as versatile channels both through weight forward coefficients. Subsequently elective OTA-C
bother strategies and constantly adjusting relationship based all-pass filter usage in view of Mitra–Hirano and
rule techniques. Gray–Markel second-arrange computerized channel
structures are inferred in which the coefficients that are
Yamada & Nishihara, (2001)adders and subtracters.
utilized to understand the denominator are partaken in
The critical path is minimized by insertion of pipeline
the acknowledgment of numerator. All the proposed
registers and is equal to the propagation delay of an
circuits are contrasted and alternate structures accessible
adder. The number of pipeline registers is limited by
in the writing. The stimulation aftereffects of the
using an equivalent transformation on a signal flow
proposed circuits was demonstrated.
graph. The price paid for the 100% speedup is 5%
increase in the area. The maximum sampling frequency Tsividis, (2010)6reviewed the event driven analog-
is 78.6MHz. to-digital conversion and related to digital signal
processing techniques. The author suggests that
Shahramian et al., (2012)8 proposed Decision
techniquesare still in the research stage and can possibly
feedback equalizer (DFE) architectures with changing
lessen the utilization of energy and data transmission
quantities of discrete-time taps and continuous time IIR
assets in a few critical applications.
filters are thought about for use in run of the mill
wireline filters. For every situation, the DFE coefficients Azim et al., (2011)4 suggested most generally
are enhanced to minimize a cost capacity that similarly utilized digital channels are FIR channels that are
weights both jitter and vertical eye opening. typically implemented with the transversal structures.
Notwithstanding when a few reflections are available For FIR channel, the signal output is a direct mix of
persistent time IIR taps can be successful if their channel coefficients that generates a quadratic capacity
channel coefficients are appropriately enhanced. (mean-square-error) along with the specific optimal
Utilizing a DFE engineering with just two IIR operation point. FIR filter then again be acknowledged
channels gives satisfactory outcomes to both a 26- dB for getting changes in examination of transversal
misfortune persuade link and a 16 FR-4 back-plane channel structure for speed of union, computational
channel at 10 Gb/s while keeping the DFE intricacy multifaceted nature and finite word length properties.
low. Moreover, the usage and exploratory aftereffects of IIR separating strategies display solid option for
a DFE with different (three) IIR channels is accounted customary FIR sifting. The central favorable position of
for. Generated in a 0.13 µm CMOS handle, the DFE IIR channels is lesser parameterization to accomplish
uses17.3 mW from a 1.2 V supply. A BER of 10−12 was at standard execution of FIR channels. Moreover, the
accomplished at an information rate of 3.7 Gb/s. pole zero structures facilitate their displaying in physical
frameworks.
Kamat et al.,(2010)5 suggested dynamic resistor–
capacitor (RC) channels utilizedoperation amps and C.Dai (2010)10 proposed new parallel FIR filter
its alteration by Moschytz are notable to dynamic RC structures, which are valuable to symmetric coefficients
filter designs. This utilization first-arrange all-pass as far as the equipment cost, under the condition that
organizes in a negative feedback loop. New present the quantity of taps is a multiple of 2 or 3. The proposed
mode all inclusive operational trans conductance parallel FIR structures exploits the innate way of
amplifier-capacitor (OTA-C) biquad channels in view symmetric coefficients lessening a large portion of the
of the TG dynamic RC channel was considered for this quantity of multipliers in sub channel segment to the
study. Furthermore, the author suggested that these detriment of extra adders in preprocessing and post
depend on the proposed OTA-C based first-arrange all- handling squares. Trading multipliers with adders is
passnetwork. Three diverse input plans were explored in favorable in light of the fact that adders weigh not as
the proposed digital filter structure to lessen the Q pole much as multipliers as far as silicon region; what’s
sensitivity. The proposed biquad channels are more,
appeared
51 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 51

the overhead from the extra adders in preprocessing

and postprocessing squares remain settled and do not
increment alongside the length of the FIR channel,
though the quantity of lessened multipliers increments
alongside the length of the FIR channel.

Implementation of FIR Filter

Multiplier based implementatio: A filter is employed

to adjust the parameters of applied signal in order to
meet our requirement.. A digital filter acts over digital
data. (a series of 1&0s, obtained by the sampling and
quantizing an analog data) also develops a digital data... Figure 2: Power consumption Comparison of
These specifications, in linear convolution by the key in Multipliers
sequence provide the required yield. In the Figure.1, the
multiplier part is represented with the Line and column Multiplier Less Implementation:
bypassing multiplier.
ARM processor implementation of Proposed
Medical signal filter: ARM Cortex M4 processor
have an extremely superior set of multiply-combine
commands that can execute more than one integer
multiply-combine operation in one clock period (e.g.
SMLAD), which leads them to perform better in digital
signal processing.

The simple idea for building a digital filter is to

Figure 1: The FIR filter with order L Comparison of employ Micro Modeler DSP, which gives a browser-
based, self-sufficient filter design situation. Pull a
FIR filters with Different multipliers: filter to the function and visually organize the filter’s
The Booth multiplier in which the multiplication of one frequency reaction. Once response is organized, copy
of two pre determined value with a product takes place and paste the robotically developed code into a .c and an
to get the result .Wallace tree multiplier is one which h file and add to the project. All of the filters developed
uses AND , half and full adders.FIR Filter can be by Micro Modeler DSP utilize the equal interface, so
constructed with bypassing multiplier instead of other it’s simple to change to another filter with no change in
multipliers the figure 2 shows the power consumption present function code. It can be chosen to develop a
performance of different multipliers. code that uses C, CMSIS DSP libraries or mixed C and
ARM Assembly depending on user preference.

This example explains the usage of the Code Replacement Library (CRL) for ARM processor with DSP blocks.
The wave form is as shown in figure.3.

Task 1: Setup and Simulate

1. Open the ex_fir_ne10_tut_ml example function, which implements a lowpass FIR filter object.
2. Create two sine wave signals with 1KHz and 3KHz frequency, respectively.
sin1 = dsp.SineWave(‘Amplitude’,1,’Frequency’,1000,...
‘SampleRate’,8000, ‘SamplesPerFrame’, 76,...
‘OutputDataType’, ‘single’);
sin2 = dsp.SineWave(‘Amplitude’,4,’Frequency’,3000,...
‘SampleRate’,8000, ‘SamplesPerFrame’, 76,...
‘OutputDataType’, ‘single’);
3. Create a spectrum analyzer to view the spectrum of the input and filtered output.
scope = dsp.SpectrumAnalyzer(‘SampleRate’,8e3,’ShowLegend’,true,...
‘PlotAsTwoSidedSpectrum’, false, ...
‘RBWSource’, ‘Property’,...
‘RBW’,8000/260, ‘Window’,’Kaiser’, ...
‘OverlapPercent’, 80,...
‘YLimits’, [-76 56], ‘SpectralAverages’,10);
4. Simulate the example
NN = 2000;
for k = 1:NN
x1k = sin1(); % generate 1K Hz sine wave
x3k = sin2(); % generate 3K Hz sine wave
n1 = randn(size(x1k), ‘single’)*sqrt(.05); % generate noise signal
u1 = x1k+x3k+n1;
y1 = ex_fir_ne10_tut_ml(u1);
scope([u1,y1]);
end

Figure 3. Output signal from Spectrum analyzer.

Task 2: Configure for Code Replacement 4. Click on the ex_fir_ne10_tut_ml.c file. Notice
1. Create a code generation configuration object for the NE10 functions, ne10_fir_init_float and
use with codegen when generating a C/C++ static ne10_fir_float_neon in the ex_fir_ne10_tut_ml
library. function.
cfgEx = coder.config(‘lib’); Task 4: Verify the generated C code on
cfgEx.CodeReplacementLibrary = ‘ARM target
Cortex-A’;
The generated code can be compiled and executed on
cfgEx.HardwareImplementation. ARM Cortex-A target by using a user- selected tool
ProdHWDeviceType = ‘ARM Compatible- chain.
>ARM Cortex’;
Run the following code to delete the temporary
cfgEx.GenCodeOnly = true;
directory.
2. Open the Custom Code panel of the configuration
dialog and verify the settings. status = tempdirObj.cleanUp;

cfgEx.dialog
Results and Discussion
Task 3: Generate code
Comparison with Multiplier based implementations:
1. Change your current folder in MATLAB to a The improved multiplier less ARM processor
temporary writable folder. Copy the MATLAB
implementation having less delay of only 10.2 ns and
file to the temporary folder.
consumes only 102 mw power as Shown in Table 1and 2.
Tablel 1: Delay Comparison of similar methods
tempdirObj = armcortexadstexample.
dstTempdir(‘ex_fir_ne10_tut_ml_workflow’);
dstarmsrc = which(‘ex_fir_ne10_tut_ml’); Methods Delay ns.
dstarmtmpdir = tempdirObj.tempDir; Multiplier less method 10.2
Modified Booth 10.22
type(fullfile(dstarmsrc))
Modified Booth with Wallace Tree 8.9
copyfile(dstarmsrc, dstarmtmpdir, ‘f’); Distributed Arithmetic 18.9
function y1 = ex_fir_ne10_tut_ml(u1) Distributed Arithmetic with Partition 16.804
Table 2: Power consumption Comparison of similar
% Copyright 2014-2016 The MathWorks, Inc.
methods
%#codegen Power
persistent fir; Methods Table consumption in
mw.
if isempty(fir)
Multiplier less Method 102
fir = dsp.FIRFilter(‘Numerator’, fir1(63, 0.33)); Modified Booth 125
end Modified Booth with Wallace Tree 250
Carry save method 290
y1 = fir(u1);
end
Medical signal Display and Transmission With ARM
2. Generate C code for the MATLAB function ex_ processor: If this proposed method is used in medical
fir_ne10_tut_ml.m.
applications like filtering of ECG and other medical
codegenex_fir_ne10_tut_ml-argssingle(u1)- signals, due to the presence of ARM controller some
configcfgEx-report other measurement, control ,display and transmission
3. When code generation finishes successfully, click of the signal to some other remote location also can be
View report to display the code generation report. done without additional processor.
The inputting and the handling of EMG signal Conclusion
is completed using LPC-2103 microcontroller unit.
The LPC- 2103 is 32-bit ARM-7TDMIS processing In this work we also projected and implemented a
unit, using on-time emulation that associates the portable filter for real-time and personal purposes. We
microcontroller unit with 32 KB implanted quick flash reduced the hardware complexity by using the digital
memory. Owing to unit’s miniature dimension and little filter-driven hardware architecture. According to the
power utilization, the LPC -2103 is perfect in areas experimental results, the proposed filter with ARM
wherever dimension is main constraint. processor has lower computational complexity than
other existing filtering algorithms. The minimized
For monitoring heart activity the ECG signal is number in hardware of this idea offers the benefit such
used. Our system is divided into three subsystems as less consumption of space and power for overall
1.ECG Acquisition 2.Processing in ARM7 3.GSM.This system including signal transmission and display. As
is real time system. In this project we will design for the ARM processor can also be used for signal
monitoring of ECG data using ARM7 LPC2148 and transmission and display the revised filter has less
GSM module .Here first data is acquired using ARM7 delay and power.
which is further sent wirelessly using GSM. The device
will be economical. It will be helpful for the patient and Ethical Clearance: NA
doctor for easy Monitoring. It will be less complex as
Source of Funding: Self
compared to other technology. Less Power is required
for its operation and control of the device. This device Conflict of Interest: Nil
is used in Hospital, Military, Homecare Unit, and Sports
Training. REFERENCES
The block diagram of this system is as shown 1. Quan, Q., &Cai, K. Y. (2012). Time-domain
in the figure 4.The hardware system consist of ECG analysis of the Savitzky-Golay filters. Digital
acquisition, ARM7 processor and GSM module. In Signal Processing: A Review Journal, 22(2), 238–
this system, ECG signal are acquired using 3 lead ECG 245. https://doi.org/10.1016/j.dsp.2011.11.004
electrodes .This signal are given to ARM7 processor for
2. Kucic, M., Hasler, P., Dugger, J., & Anderson, D.
amplification and filtration.
(2001). Programmable and adaptive analog filters
using arrays of floating-gate circuits. Proceedings
- 2001 Conference on Advanced Research in
VLSI, ARVLSI 2001, 0, 148–162. https://doi.
org/10.1109/ARVLSI.2001.915557
3. Azami, H., Mohammadi, K., &Behzad, B. (2012).
An Improved Signal Segmentation Using Moving
Average and Savitzky-GolayFilter.Journal of
Signal and Information Processing, 3(1), 39–44.
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GSM (Global System for Mobile communication 4. Azim, C. F., Ahmed, S. F., &Memon, A. R.
or Groupe Speciale Mobile) communications, initiated (2011).
by the European Commission, is the second generation On the optimal design of IIR filter with its state-
mobile cellular system aimed at developing .GSM is the space realization, 4(9), 1021–1024.
world’s most popular 2G technology. It was developed 5. Kamat, D. V., Ananda Mohan, P.
to solve the fragmentation problems of the first cellular V.,
system in Europe.GSM promised a wide range of &GopalakrishnaPrabhu, K. (2010). Current-mode
network services through the use of ISDN. It also operational transconductance amplifier-capacitor
specifies digital modulation and network level biquad filter structures based on Tarmy–Ghausi
architectures and services. Active-RC filter and second-order digital all-pass
filters. IET Circuits, Devices & Systems, 4(4),
346. https://doi.org/10.1049/iet-cds.2009.0213
6. Tsividis, Y. (2010). Event-Driven Data independent control of pole frequency and quality
Acquisition and Digital Signal Processing factor. Radioengineering, 21(3), 886–891.
#x2014;A Tutorial. IEEE Transactions on
10 .C. Dai, W. Chen, & Y. Zhu. (2010). Seeker
Circuits and Systems II: Express Briefs, 57(8),
Optimization Algorithm for Digital IIR Filter
577–581. https://doi.
Design.IEEE Transactions on Industrial
org/10.1109/TCSII.2010.2056012
Electronics, 57(5), 1710–1718. https://doi.
7. Yamada, M., & Nishihara, A. (2001).High- org/10.1109/TIE.2009.2031194
speed FIR digital filter with CSD coefficients
11. Dastjerdi, M. M., A. A. Kusha., and Pedram
implemented on FPGA.Proceedings of the Asia
M., 2009, “BZ-FAD: A LowPower Low-Area
and South Pacific Design Automation Conference,
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C. (2012).Decision feedback equalizer
(2016). Low-Power FIR Filter Design Using
architectures with multiple continuous-time
Hybrid Artificial Bee Colony Algorithm with
infinite impulse response filters.IEEE
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(2012). MISO current-mode biquad filter with
DOI Number: 10.5958/0976-5506.2019.01536.5

Effect of Inpatient Physiotherapy Intervention Versus Delayed

Outpatient Physiotherapy Intervention in Post Stroke
Hemiplegic Individuals

Pragati V. Salunkhe1, G. Varadharajulu2, Suraj Kanase3

1
Faculty, 2Dean, Faculty of Physiotherapy, 3Associate Professor, Krishna College of Physiotherapy,
KIMS
‘Deemed to be’ University, Karad, Maharashtra, India

ABSTRACT
Objectives: The purpose of this study was to evaluate the effect inpatient physiotherapy intervention,
outpatient physiotherapy intervention and compare inpatient physiotherapy intervention versus delayed
outpatient physiotherapy intervention in post stroke hemiplegic individual.
Method: 44 subjects diagnosed with post stroke hemiplegia were included in this study. Subjects were
divided into two different groups. Group A was inpatient and group B was delayed outpatient group. These
subjects were allocated by convenient sampling method. During Pre and post treatment assessment
functional independence and mobility were assessed by outcome measures Functional Independence
Measure and Barthel Index. These outcome measures were analysed.
Result: Pre and post functional independence and mobility was analysed by using paired and unpaired t
test. Data analysis showed significance for FIM and Barthel Index (p value less than 0.001) for both the
groups but comparative to group B (delayed outpatient), group A (inpatient) is more effective.
Conclusion: Inpatient physiotherapy intervention and delayed outpatient physiotherapy intervention is
effective in improving the functional independence and mobility in the post stroke hemiplegic individuals
but comparative to delayed outpatient physiotherapy intervention, inpatient physiotherapy intervention is
more effective.

Keywords: Inpatient, Delayed outpatient, Physiotherapy Intervention, Post Stroke Hemiplegia.

Introduction Disturbance in blood supply may be due to ischemia
i.e lack of blood flow caused by blockage (thrombosis,
Stroke can be defined as “Rapidly developed
arterial, embolism) or haemorrhage (leakage of
clinical sign of focal (or global) disturbances of cerebral
blood)
function lasting more than 24 hours or leading to death, 3
. About 80% of individuals are affected by
with no apparent cause other than vascular origin”1 ischemic
Stroke may cause a disturbance in the blood supply stroke; which is the most common type of stroke.1
to
the brain and may lead to rapid loss of brain functions. Stroke is one of the leading causes of death &
disability in India. Stroke is the third commonest cause
of death according to the statistics.4 The estimated
Corresponding Author: average prevalence rate of stroke range 84-262/100,000
Pragati Vishwasrao Salunkhe in rural and 334-424/100,000 in urban areas. The
MPT, Faculty of Physiotherapy, incidence rate is 119-145/100,000 4
Krishna Institute of Medical Sciences
Deemed to be university, According to the American Physical Therapy
Karad 415110, Maharashtra, India Association (APTA), ‘‘physical therapists are health
Phone: 9730830011 care professionals who maintain, restore, and improve
Email: [email protected] movement, activity, and health, enabling an individual
to have optimal functioning and quality of life,
while
57 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 57

ensuring patient safety and applying evidence to provide sleep or understanding, sudden difficulty in seeing
efficient and effective care. Physiotherapists assess, in
diagnose, and treated individuals of all age groups who
have impairments, activity limitations, and participation
restrictions, promoting health.5

Stroke can result in a many symptoms and signs

but the most common symptom is motor impairment.
Which typically affects the control of movement of the
face, arm, and leg of one side of body characterized
by paralysis (hemiplegia) or weakness (hemiparesis)
typically on the one side of body opposite to the side
of lesion. Immediately after stroke, there is an initially
flaccid paralysis in over 90% of individuals, which is
often replaced by spasticity lasting for 24 hours to
12-
18 months.5 In acute phase, about 50 to 80% of
stroke
patients has various impairments in the body.6

Pathophysiology: The pathophysiology of stroke, If

presence of prolonged state of hypotension, stenosis
of measure cerebral arteries or internal carotid artery
following thromboembolism or due to episode of sudden
cardiac arrest, the brain cells undergo a state of
nutritional deprivement which leads to Ischaemic
Hypoxic Cerebral injury and result in formation of acute
infarction which initially is soft and swollen but
eventually herniates compressing the vital structure in
the brain. Acute infarction if not reversed within 3
minutes undergoes a permanent damage and heals in the
form of a firm cyst known as gliosis. The dense central
core of this region consist of dead neurons referred as
penumbra region has a chances to reversal of symptoms
if perfusion is established within 3 hours. In neuronal
injury resultant of increased cytosolic calcium
concentration due to failure of ionic pumps. Ionic leaks
changes the sodium and potassium ion gradient which
create a state of acidosis with release of free radicals
disrupting the Blood Brain Barrier. Following Hypoxia,
the brain fails to maintain normal concentration of
ATPs. This energy depletion delays the resynthesis of
macromolecular proteins essential for endothelial cell
structure and function. Proteolysis and lipolysis result
in production of arachidonic acid and platelet activating
factors which further activates the release of cell
adhesion molecules, free radicals resulting in more brain
damage.7

Warning Signs: Warning signs of stroke are sudden

numbness or weakness of the face, arm or leg, especially
on one side of the body, sudden confusion, disturbed
58 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 58
one or both eyes, sudden severe headache with unknown
cause sudden difficulty in walking, dizziness, loss of
balance or coordination.2

Physiotherapy Intervention: The physiotherapy

intervention that is exercise is to improve mobility,
increase functional independence, relive pain, and
minimise limitations due to permanent disabilities.
Stroke is a chronic condition, we have to spend the
more time of rehabilitation, from the early stage that is
inpatient in the acute care hospitals physiotherapy
intervention are the primary mechanism by which
functional recovery, mobility and functional
independence of patient are achieved in stroke.9

Conventional Exercises: Conventional exercises are

exercises that are traditionally practiced since ancient
times and are accepted worldwide. Conventional
training for stroke survivors include Passive movement,
sustained stretching, active assisted RIMP to both the
limbs, bed mobility exercises, Gait training. These
exercises can also be performed with the help of various
modifications and may help to achieve a faster recovery
at least to improve the patient’s functional performance.8

Timing of Interventions: Patient those who are

admitted in a hospital with a stroke are referred to
physiotherapy when medical condition is stable. All
stroke patient received physiotherapy while they are
admitted in wards, so in inpatient the recovery was
good. On discharge from the ward, the stroke patients
are advised to return as physiotherapy OPD but, a large
number of patient deteriorate after discharge from the
hospital, so in delayed outpatient the recovery was poor
as compared to inpatient. At a global level, many
patients with a stroke not attending outpatient
physiotherapy intervention, this according to the review
study by Thomas and parry. In another study was
conducted in United States (Barclay2007), 30% of post
stroke hemiplegic individual reported that they were
attending outpatient physiotherapy .9 The more number
of patient in the study lived in rural areas. Every day
they had to travel long distant from their home for
physiotherapy intervention so the flow of outpatient was
reduced.10

The stroke patient who are admitted in hospital

they are taken physiotherapy treatment regularly, but
after discharge some of them delay or discontinue the
treatment. After some period they realise that there
is no functional improvement then they come back
to
the physiotherapy department .So there is necessity to by protocol and ethical committee. Group A and Group
create awareness among these people who delay the B
physiotherapy treatment. It is necessary to note that was given Conventional training exercises regularly for
still there are many regions in our country without any 4 weeks 6 days a week. After 4 weeks the post treatment
physiotherapy department providing comprehensive assessment for functional mobility was taken with the
stroke rehabilitation. help of assessment tools (Functional Independence
Measure and Barthel Index).
Method
Result
The subjects which willing to participate in the
study was taken. The criteria for inclusion were: Pre and post functional mobility was analysed by
clinically diagnosed with post stroke hemiplegia and the using paired and unpaired t test. Data analysis showed
age group 30-65 years. Subjects were excluded if any significance for FIM and Barthel Index (p value less
musculoskeletal conditions e.g. fracture, subject with than 0.001) for both the groups but comparative to group
visual and auditory impairment and subject associated B (delayed outpatient), group A (inpatient) is more
with psychological disorder. effective.

44 post stroke hemiplegia survivors were selected Statistical analysis: The data was entered into
from Krishna Hospital Karad. Subjects were divided Microsoft office excels 2007 and analyzed using
into two different groups. 22 subjects in each group, INSTAT software. Descriptive statistics were used to
group A was inpatient there were 16 male and 6 female analyze for demographic data: Pre and post treatment
and group B was delayed outpatient group there protocol was analyzed by using paired and unpaired t
were test and p value
17 male and 5 female.These subjects were allocated by <0.0001 was considered to be statistically significant.
convenient sampling method, written consent form was
taken. All the subjects were informed about the protocol Within Group Comparison
and gave written consent before their participation. The Within group comparison was done by applying
protocol and the consent form were previously approved ‘Paired t-test’ to pre and post training values of
Functional
independence measure.

Table 1: Comparison of Pre and Post-treatment average with Functional Independence Measure
Group Pre training Mean Post training Mean t value p value
Group A 54.364 69.909 11.984 < 0.0001
Group B 55.955 59.545 10.021 <0.0001

Table 2: Comparison of Pre and post-treatment average with Barthel Index

Group Pre training Mean Post training Mean t value p value
Group A 30.227 60 18.678 < 0.0001
Group B 31.364 36.818 17.390 < 0.0001

Between Group Comparison: Between groups comparison was done by applying ‘unpaired t test’

Table 3: Comparison of Pre and post-treatment average with Functional Independence Measure
Group Group A Group B t value p value
Pre training Mean 54.364 56.500 0.7822 0.4385
Post training Mean 69.909 59.545 3.517 0.0011

Table 4: Comparison of Pre and post-treatment average with Barthel Index

Group Group A Group B t value p value
Pre training Mean 30.227 37.045 2.817 0.0074
Post training Mean 60 36.818 6.795 < 0.0001
Discussion tissue. Repetitive exercises appear to be major
factors
The study “Effect of inpatient physiotherapy
intervention versus delayed outpatient physiotherapy
intervention in post stroke hemiplegic individual” was
conducted to compare the two groups to find out its
effects on functional independence and mobility. The
inpatient are the acute stroke patient they are taken
continuously 4 weeks physiotherapy intervention and
the delayed outpatient are the chronic stroke patient
they discontinue or delayed the treatment after some
period they taken continuously 4 weeks physiotherapy
intervention. This study mostly focused on the
functional independence and mobility of the
individuals and the best possible treatment for it so, the
outcome measures for this study were Functional
Independence Measure and Barthel index. The subjects
were analysed for Functional Independence and
mobility.

The loss of motor function because of stroke is

caused by cell death in the infarcted area as well as
dysfunction the areas surrounding the infarct. The
function of brain regions, including the contralateral
areas that are connected to the areas of tissue damage, is
compromised because hypo metabolism, neurovascular
uncoupling, and disrupted neurotransmission, jointly
called diaschisis. Some recovery of function occours
spontaneously after stroke. It is believed that this
functional recovery involves, to some extent
overlapping, phases: (1) reversal of diachisis, activation
of cell genesis, and repair; (2) changing the properties of
existing neuronal pathway; and (3) neuroanatomical
plasticity leading to the formation of new neuronal
connection. Neuroanatomical plasticity leading to the
formation of new neuronal connections. The basic
process underlying phases 2 and 3 also involved in
normal learning and it has been recognised that
functional improvement after brain injury is a relearning
process. 15

In stroke, physiotherapy intervention that is

conventional exercise is to minimize the effects of the
brain cell damage and optimize re-learning. It is well
recognized that for cortical re-organisation to occur post
stroke, there is a requirement for high levels of repetition
of tasks and exercises that are both challenging and
engaging.16

Conventional Exercises with patient’s following

stroke may be a stimulus for making new more
effective functional connections within remaining brain
in promoting synaptogenesis and are important in
rehabilitation of motor weakness following stroke.

Stroke severity is considered the most powerful

prognostic factor because disability is a consequence of
the severity of neurological impairment. Similarly, the
strong positive relationship between initial and later
disability is well known. Shah et al7 reported that initial
disability was a powerful predictor of discharge Barthel
Index:

(BI) score, and Oczkowski and Barreca14 found

that the absolute admission functional independence
measure score was the best predictor of outcome
disability and place of discharge. The strong positive
relationship between increasing age and disability is
well established.17

Conclusion

Through this study, it is concluded that, inpatient

physiotherapy intervention and delayed outpatient
physiotherapy intervention is effective in improving
the functional independence and mobility in the post
stroke hemiplegic individual but comparative to
delayed outpatient physiotherapy intervention, inpatient
physiotherapy intervention is more effective.

Conflict of Interest: This study can be carried out with

large sample size.

Source of Funding: This study was funded by Krishna

Institute of Medical sciences Deemed to Be University,
Karad.

REFERENCES
1. Moskowitz H, Goodman CR, Smith E, Balthazar
E, Mellins HZ. Hemiplegic shoulder. N Y State J
Med 1969; 69: 548–50.
2. Susan B. o’sullivan, Thomas J. Shmitz, et al.
Physical Rehabilitation 6th addition 645-646.
3. Jeyaraj Durai Pandian, Paulin Sudhan. Stroke
epidemiology and Stroke care services in India.
Journal of Stroke.2013;15(3):128-134.
4. Isa U. Lawal1,4*, Susan L. Hillier2†, Talhatu K.
Hamzat3† and Anthea Rhoda et al Effectiveness
of a structured circuit class therapy model in
stroke rehabilitation: a protocol for a randomised
controlled trial BMC Neurology (2015) 15:88.
5. Janne Marieke Veerbeek1, Erwin van Wegen1 Impairments and Activity Limitations.AHA.
et al What Is the Evidence for Physical Therapy Stroke. 2004;35:134-139
Poststroke? ASystematic Review and Meta-
12. Davidoff GN, Keren 0, Ring H, Solzi P. Acute
Analysis February 2014
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6. Ntamo NP, MPH1; Buso D, MSc2; Longo- and maintenance of gains. Arch Phys Med
Mbenza B, PhD, DSc3 Factors affecting poor Rehabil
attendance for outpatient physiotherapy by 1991;72:869-73.
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Medicine. 7th ed. New Delhi. Jaypee Brothers;
14. Johnstone M. Restoration of motor function in the
2003.s
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8. Gary N. Davidoff, MD, Ofer Keren, MD, Haim Livingstone, 1987
Ring, MD, Pablo Solzi, MD et al.Acute Stroke
15. Wieloch T, Nikolich K. Mechanisms of neural
Patients: Long-Term Effects of Rehabilitation and
spasticity following brain injury. Curr Opin
Maintenance of Gains Arch Phys Med Rehabil
Neurobiol. 2006.
1991;72:869-7
16. Shah S, Vanclay F, Cooper B. Predicting
9. Rose Galvin, Brendan Murphy, Tara Cusack,
discharge status at commencement of stroke
and Emma Stokes,et al The Impact of Increased
rehabilitation. Stroke. 1989;20:766–769.
Duration of Exercise Therapy on Functional
Recovery Following Stroke – What Is the 17. Roland PS Van Peppen Gert Kwakkel et al
Evidence? July-August 2008 studied that The impact of physiotherapy on
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10. Barclay L 2007 More than 30% of US stroke
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DOI Number: 10.5958/0976-5506.2019.01537.7

Effect of Therapeutic Intervention and Hand Muscle Training

on Pain and Quality of Hand Function in Subjects with
Chronic Tennis Elbow

Pranali Desai1, G. Varadharajulu2, Smita Kanase3, Sandeep Shinde4

1
MPT, 2Dean, Faculty of Physiotherapy, 3Assistant Professor, 4Associate Professor, Krishna College
of
Physiotherapy, KIMSDTU, Karad-415110, Maharashtra, India

ABSTRACT
Background: Tennis elbow is a form of repetitive injury. It results in pain at the lateral humeral epicondyle
on gripping and frequent rotatory motion of the forearm. It leads to reduce hand grip strength and causes
functional disability
Objectives: To find and compare the effect of mulligan mobilisation with movement (MWM),
phonophoresis, eccentric strengthening exercises and hand muscle training on pain and quality of hand
function in subjects with chronic tennis elbow.
Method: 30 subjects diagnosed as chronic tennis elbow were included in the study on the basis of inclusion
and exclusion criteria. In the study pre and post treatment outcome assessment was taken on (Visual
Analogue Scale) VAS, Hand Held Dynamometer and on (Patient Rated Tennis Elbow Evaluation) PRTEE.
Mulligan mobilisation with movement, phonophoresis, eccentric strengthening exercises were baseline
treatment for both the group. Group A received baseline treatment and hand muscle training and Group B
received only baseline treatment for 3 weeks treatment protocol.
Results: 30 subjects (19 female and 11 male), participated in the study. Intra group comparison results
showed statistically significant reduction in post interventional VAS, HHD, and PRTEE score for both the
groups (p <0.0001). Inter group comparison results showed Group A was statistically significant in showing
improvement in VAS, HHD, and PRTEE score than Group B (p <0.0001).
Conclusion: Group A treated with baseline treatment and hand muscle training showed significant
improvement than Group B.

Keywords: Chronic Tennis Elbow, Mulligan mobilisation, Phonophoresis, Hand muscle training, Hand
Held
Dynamometer (HHD), Patient Rated Tennis Elbow Evaluation
(PRTEE)
Introduction wrist. Functional impairment and reduced productivity
due to the pain is common symptom2. Male and
Tennis elbow is also known as lateral epicondylitis1.
females are equally affected with the peak incidence
Pain in region of epicondyle which can be elicited by
is between 30-60yr of age 3. Extensor Carpi Radialis
giving resistance to either extensor or flexor muscles of
Brevis (ECRB) is most commonly affected structure4.
The cardinal symptoms of tennis elbow are pain and
inflammation. The cause of pain maybe changes in
the
nervous system as a result of neuronal tissue changes as
Corresponding Author: well as nociceptive and non-nociceptive process5. Due to
Pranali Pradeep Desai which subjects shows difficulty to perform the gripping
MPT, Krishna College of Physiotherapy, activities and exhibit reduced grip strength 6. In various
KIMSDTU, Karad-415110, Maharashtra, India daily activities hand grip strength is vital 7. Improve the
Phone: 9029631646 quality of hand function is essential as it enhance the
Email: [email protected] functional ability and prevent the recurrence.
62 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 62

Among various available physiotherapy treatment were given hand muscle training and baseline treatment
options8 Phonophoresis is a therapeutic method gives and Group B were given only baseline treatment for 3
combined effect of ultrasound and nonsteroidal anti- weeks 5days/week. Pre and post treatment assessment
inflammatory drug which helps to resolve pain and were done with VAS, Hand Held Dynamometer and
inflammation9. Mulligans mobilisation with movement PRTEE questionnaire. Post treatment assessment was
is relatively quick with active participation of subject taken on Day 7, Day 14 and Day 21.
in treatment. which results in immediate pain reduction
and improvement in function 10. As there is paucity Baseline treatment:
of literature on combined effect of phonophoresis
Phonophoresis: in sitting position. Mode continuous,
and MWM and no study has concerted on improving
Frequency 1 MHz, intensity 0.8 W/cm2 over the area of
the quality of hand function in subjects with chronic
the lateral epicondyle for 5 minutes.
tennis elbow the present study is intended to find out
the combined effect of Phonophoresis, MWM and Mulligan mobilisation with movement: In supine
effect of Hand muscle training on the pain and quality position forearm pronated, lateral glide to the proximal
of hand function in subjects with chronic tennis elbow forearm was sustained for 5-10 sec for 3 repetitions
to improve the quality of hand function and to avoid progress to 6 repetitions.
functional disabilities.
Eccentric strengthening exercise: In seated position
with elbow in extension, forearm in pronation, and wrist
Materials and Method
in full extension. subject was asked to slowly lower the
Participants: On the clinical screening using special wrist into flexion for a count of 30 and again return back
test 30 subjects who diagnosed as chronic tennis elbow to the wrist full extension for 3 sets of 10 repetitions.
based on inclusion and exclusion criteria were selected.
Hand Muscle Training:
Both male and female between age group 35-55 yr,
willing to participate were included in the study. Written 1. Exercise With Exercise Ball: In sitting position
consent was taken. Inclusion criteria were as with elbow at 900 of flexion , wrist in neutral
follows: and fingers are spread around the exercise ball .
1) more than 3 months symptom duration 2) Pain with subject was asked to squeeze the exercise ball and
gripping at lateral humeral epicondyle 3) Tenderness on then released.
palpation over lateral epicondyle of humerus 4) Subjects 2. Rubber Band Exercise: Rubber band was
having pain on resisted extension of third finger 5) wrapped around the finger and subject was asked
Positive mills test 6) Previous physiotherapy treatment to performed extension of finger for 3 sets of 10
for tennis elbow. Exclusion criteria were as follow: 1) repetitions.
Subjects having tenderness within the muscle 2) 3. Supination with Dumbbell: In sitting position
Cervical radiculopathy 3) Previous fracture or tendon with elbow resting on plinth holding dumbbell
rupture in elbow. Intensity of pain on VAS, hand grip vertically and asked to rotate the arm outword
strength on Hand held dynamometer and functional so that palm turns up. Then again rotate the hand
disability on PRTEE SCALE was recorded pre- inward so the palm faces downward. Repeat 10
interventional and post interventional. times 3 sets.
Interventions: 30 subjects were divided into two group 4. Twisting a Towel: Grasp the towel horizontly
(n=15 in each group) by simple lottery method. Baseline in the hand. And twist it into the roll. Repeat 10
treatment for both the group was phonophoresis, times 3 sets.
mulligan mobilisation, eccentric exercises. Group A
Data Analysis

Table 1: Comparison of VAS score at rest between group

Groups Pre-treatment Post- treatment
Day 1 Day 7 Day 14 Day 21
Mean ± SD Mean ± SD Mean ± SD
A 5.12 ± 1.460 3.5 ± 1.242 1.8866 ± 0.814 0.7866 ± 0.4833
B 4.4933 ± 1.599 3.8866 ± 1.429 3.3666 ± 1.171 2.22 ± 1.080
U’ 126 137 185.50 194.50
P 0.5897 0.3195 0.0026 0.0007
Significance Not significant Not significant Very significant Extremely significant

The pre-treatment values were 5.12 ± 1.460 for group A and 4.4933 ± 1.599 for group B respectively and post
interventional value for group A was 0.7866 ± 0.4833 and in group B was 2.22 ± 1.080. It showed VAS SCORE
AT REST between group A versus group B statistically very significant difference. This was done by using
unpaired ‘t’ test. (Mann-Whitney test)

Table 2: Comparison of VAS score on activity between group

Groups Pre-treatment Post- treatment
Day 1 Day 7 Day 14 Day 21
Mean ± SD Mean ± SD Mean ± SD
A 7.8466 ± 0.6823 5.4733 ± 0.8908 3.5266 ± 0.7842 1.58 ± 0.4632
B 8.1066 ± 1.428 7.02 ± 1.372 5.94 ± 1.251 4.5266 ± 1.146
U’ 143.50 185.50 210.00 222.00
P 0.2058 0.0026 <0.0001 <0.0001
Significance Not significant Very significant Extremely significant Extremely significant

The pre-treatment values were 7.84 ± 0.68 for group A and 8.1066 ± 1.428 for group B
respectively and post interventional value for group A was 1.58 ± 0.4632 and group B was 4.5266 ±
1.146. It showed VAS score ON ACTIVITY between group A versus group B statistically very
significant difference. This was done by using unpaired ‘t’ test. (Mann-Whitney test)

Table 3: Comparison of Hand Grip Strength within group

Groups Pre-treatment Post- treatment p value
Day 1 Day 7 Day 14 Day 21
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
p <0.0001,
A 6.6 + 2.613 13.8 ± 3.212 21 ± 2.591 24.46 ± 2.100
Fr = 42.920
p <0.0001,
B 6.46 + 2.100 11.8 ± 1.971 15.4 ± 1.804 19.26 ± 2.01
Fr = 45.040

The pre-treatment values were 6.6+2.613 in group A and 6.46+2.100 in group B respectively, were as post
interventional value for group A was 24.46+2.100 and group B was 19.26+2.01. It showed extremely significant
INCREASE in HAND GRIP STRENGTH for both the groups. This was done by using paired ‘t’ test (Friedman test
with post-test)
Table 4: Comparison of Hand Grip Strength between groups
Groups Pre-treatment Post- treatment
Day 1 Day 7 Day 14 Day 21
Mean ± SD Mean ± SD Mean ± SD
A 6.6 ± 2.613 13.8 ± 3.212 21 ± 2.591 24.4666 ± 2.100
B 6.466 ± 2.100 11.8 ± 1.971 15.4 ± 1.805 19.2666 ± 2.017
U’ 115.00 148 221.00 217
P 0.9336 0.1451 <0.0001 <0.0001
Significance Not significant Not significant Extremely significant Extremely significant

The pre-treatment values for group A 6.6 ± 2.613 and 6.466 ± 2.100 in group B respectively, were as post
interventional value for group A was 19.2666 ± 2.017 and group B was 24.4666 ± 2.100. It showed statistically very
significant difference. This was done by using unpaired ‘t’ test. (Mann-Whitney test)

Table 5: Comparison of PRTEE score within group

Groups Pre-treatment Post- treatment p value
Day 1 Day 7 Day 14 Day 21
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
p <0.0001
A 63.13 ± 6.553 49.8 ± 9.147 38.9666 ± 7.763 23.7333 ± 6.397
Fr= 45.000
p <0.0001
B 65.0333 ± 11.889 52.3 ± 7.894 41.3666 ± 6.269 31.4333 ± 4.57
Fr=45.000

The pre-treatment values were 63.13 + 6.553 for group A and 65.0333 + 11.889 for group B respectively, were
as post interventional value for group A was 23.7333 + 6.397 and group B was 31.4333 + 4.57. PRTEE SCORE
showed extremely significant increase in functional ability for both the groups. This was done by using paired ‘t’
test (Friedman test with post-test)

Table 6: Comparison of PRTEE SCORE between groups

Groups Pre-treatment Post- treatment
Day 1 Day 7 Day 14 Day 21
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
A 63.1333 ± 6.553 49.8 ± 9.147 38.9666 ± 7.763 23.7333 ± 6.397
B 65.0333 ± 11.889 52.3 ± 7.894 41.3666 ± 6.269 31.4333 ± 4.574
U’ 136.50 137 145 191.50
P 0.3297 0.3192 0.1842 0.0011
Significance Not significant Not significant Not significant Very significant

The pre-treatment value for group A 63.1333 ± 6.553 and 63.0333+11.889 for group B respectively, were as
post interventional value for group A was 23.7333 ± 6.397 and group B 31.4333 ± 4.574. PRTEE SCORE showed
statistically very significant difference. This was done by using unpaired t’ test. (Mann-Whitney test)

Discussion

The present study was undertaken with the aim to evaluate the effect of therapeutic intervention and hand muscle
training on pain and quality of hand function in subjects with chronic tennis elbow.
Study included 30 subjects. It affects both the sexes Lateral glide to elbow joint helps to reposition the
commonly and it appears to be more severe and of ulna and radius in relation to the humerus15.
longer duration in females 11,12. which correlates in this
study. Eccentric strengthening exercises and hand muscle
training helps to reduce the pain and improve quality of
Tennis elbow is common in age group between 30 hand function.
and 60 years of age3. Subjects of the age group 35-55
were included in the study. The inclusion of sample in Strength training is type of resistance that induces
this study supports the prevalence rate of above study. muscular contractions that results in building the
strength and size of skeletal muscles16.
According to study mean value of age for Group A
It improves Strength, grip strength and endurance
was 40.4 and for Group B was 40.06, which is
thus it leads to improvement in hand function.
considered as not significant. Statistical analysis was
done using nonparametric unpaired t test for between Recent evidence has indicated that the combination
group analysis and paired t test was used for within of exercise training with electrotherapeutic modality
group analysis.

Statistical analysis showed that post treatment there

was extremely significant difference in VAS score at rest
in both the groups(p=0.0007). (Table 1) which produces sensory input which results in analgesic
effects
Statistical analysis showed that post treatment there
was extremely significant difference in VAS score on
activity in both the groups (p=0.0001) (Table 2)

Group A was more efficient in improving Hand Grip

Strength than Group B post treatment. (Table 4)

Statistical analysis showed that post treatment

there was extremely significant difference in Hand grip
strength in both the groups (p <0.0001)

Statistical analysis showed that post treatment there

was very significant difference in PRTEE score in both
the groups (p=0.0011)

Group A was more efficient in improving functional

disability than Group B post treatment. (Table 5, 6)

In phonophoresis ultrasound facilitates the passage

of some drug into and through the skin and the effects
are due to absorption of the drug and also due to the
ultrasound13

Reduction of inflammation is achieved with the

phonophoresis as it causes elevation of the pain
threshold and alteration of neuromuscular activity
which leading to muscle relaxation, induction of tissue
regeneration.

A Paungmali et al (2003)14 showed there is

sufficient recruitment and activation of descending pain
inhibitory systems following application of MWM
17

correlates in this study.

The findings in study were consistent with the

experimental study. And it showed the significant
reduction in intensity of pain and improvement in hand
grip strength and functional disability on the outcome
measure, VAS, Hand held dynamometer and on PRTEE.
Hand muscle training yields better outcome in
improving hand grip strength and functional disability.

Result

Based on the results of the present study it is

concluded that both the Groups showed significant
reduction in VAS and improvement in HHD and PRTEE
score. Group A showed extremely significant result than
Group B in subjects with chronic tennis elbow.

Conclusion

Results supported that hand muscle training with

baseline treatment was more effective than only baseline
treatment in reducing pain and improving quality of
hand function.

Conflicts of Interest: There were no conflicts of interest

in this study

Ethical Clearance: Ethical clearance was taken from

institutional committee of Krishna institute of medical
science, deemed University, Karad.

Source of Funding: Source of funding is Krishna

institute of medical sciences deemed University, Karad
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DOI Number: 10.5958/0976-5506.2019.01538.9

Assessment of Balance in Children with Developmental

Coordination Disorder in Indian Context

U. Ganapathy Sankar1, R.Monisha2

1
Dean, Srm College of Occupational Therapy, Srm Institute of Science and Technology, India,
2
Assistant Professor, Srm College of Physiotherapy, Chennai, India

ABSTRACT
Background: Children with Developmental Coordination Disorder (DCD) have inability in performing
physical activity as like the peer group children of same age and they have deficit in motor control and
encounter imbalance when exposed to gait initiation in an unfamiliar environment. It has been shown that
imbalance leads to inhibition of gait adaptations which is evident by shorter steps, greater trunk inclination,
decreased ankle plantar and dorsiflexion
Methodology: The children who participated in this study were selected from various elementary schools
in and around Chennai. There were 100 children in the age group of 8-10 years old. After getting informed
consent signed, all children were evaluated using Body Coordination Test for children - BCTC. Initially at
the baseline all the 100 children were evaluated with MABC
Discussion: The present study examined the movement difficulties in children with DCD and to examine
the balance ability between children with Developmental Coordination Disorder (DCD) and NON-DCD
Group. The Body Coordination Test for Children was used in this study since the test examines the
assessment of children’s coordinative performance.
Result: The results showed that children participating in this study exhibited difficulty in balance along
with
the motor coordination difficulty indicating the existence of DCD disorder
Conclusion: Children with DCD physically, psychologically and socially avoid participating in physical
activities in order to avoid injuries due to their difficulty in balance. Thus, early identification and treatment
of balance control difficulties are in increasing need.

Keywords: DCD, MABC, BCTC, BALANCE, INCOORDINATION

Introduction place to place without tripping or falling. Majority of
Children with Developmental Coordination researchers have highlighted that these children without
Disorder (DCD) have inability in performing physical evaluation of their gait patterns and reasons of fall
activity as like the peer group children of same age. This during their locomotion will be reported to have the
inability is due to poor motor coordination. Children persistent difficulty in adolescence2.
with DCD have difficulties in performing activity of Teachers and parents commonly call these children
daily living, which makes them isolated from the peer as clumsy, awkward in walking. Therapist working
group of same age in school and sometimes at home too. with DCD children have identified different gait pattern
If this isolation continues for a long period of time might and they found to have difficulty in walking and loose
leads to long term health and psychological issues1. balance when certain new object has been interfered
in their walking space in a familiar environment. They
Walking is an essential skill that needs to be reported to have frequent sway, stumbling and hitting
acquired by all the children at the age of one. Children to objects in the pathway. When the Gait pattern of
with DCD experiences difficulty in achieving this task these children has studied in detail, children with DCD
and they find walking as a difficult and complex task to walked with shorter steps and at a higher cadence than
perform. They experience difficulty in locomotion from the typically developing children3.
68 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

It has been known that, DCD is not caused by selected in the study shows motor difficulties and
neurological or any other pathological condition and identified as DCD disorder. Control group of 20 children
its prevalence is reported to be 2-3% in southern India. with NON-DCD has been randomly selected from the 80
Deficit in proprioception and perception makes these subjects found to have low score on MABC
children clumsy, however, it remains unclear how the
impairment in motor control contribute to the The 20 students diagnosed with DCD were matched
completion of daily activities4. with Non-DCD children according to gender and age to
avoid environmental and educational influences causing
However children with DCD reported to lose bias. Enrolled children’s have normal IQ documented
balance when they were exposed to new environment with WISC and children’s with No physical or
and they have a poor visual- proprioception that neurological disorder. Any history suggestive of sensory
hampers the gait pattern and increases the incidence of impairment, epilepsy was excluded from the study9.
fall. When Obstacle crossing is examined in children
with DCD, it has been clear that children lose balance However information regarding the activity of
control and fall, because it demands precise balance daily living and academic achievements and the impact
control using perceptually driven postural adjustments. difficulty in coordination with physical activity and
Previous researches in traumatic brain injury patients performance has been evaluated and documented. Age
and their balance control during obstacles crossing and intellectual ability of the children was derived
during the initiation of normal walking has concluded from school reports and records according to the
that imbalance and postural sway has reported, when the recommendations of APA
patients encounter hurdles or obstacles in the pathway5.
Body Coordination Test for Children evaluates
Children with DCD have deficit in motor control the overall body co-ordination and balance control of
and encounter imbalance when exposed to gait initiation children from 5 to 14 years old. It is gold standard in
in an unfamiliar environment. It has been shown that assessment of children with DCD. This test measures the
imbalance leads to inhibition of gait adaptations which overall body coordination by children performing four
is evident by shorter steps, greater trunk inclination, tasks: retro walking, obstacle jump on one foot,
decreased ankle plantar and dorsiflexion6. sideways movements with initial position and side
jumps. In side jumps children were instructed to jump
Literatures with the established difficulties with
sideways over a hurdle within a period of 15 seconds.
balance and visual perception, children with DCD
were expected to demonstrate more signs of instability The instructions provided to each children is similar
and less accurate foot positioning leading to more to avoid influence of motivation in test performance for
unsuccessful Gait initiation. But none of the researchers the four subtests a raw score (RW) is recorded. A Motor
have documented which activity has imposed a sway Quotient (MQ=100) percentiles is estimated per item as
and instability in children’s with DCD. Hence the study well as for the global test. A score less than 85 indicates
is conducted with the Aim to evaluate balance coordination difficulty. Balance testing was performed
limitations in Children with Developmental on a pressure platform. All the children were asked to
Coordination Disorder (DCD) and typically developing perform one-leg stance and double-leg. They were
(TD) children7. instructed to stand motionless on the platform. They can
adapt the normal posture and arms should hang at the
Methodology side. Posture should be maintained for 30 seconds10.

The children who participated in this study were Each task has to be repeated with eyes open and
selected from various elementary schools in and around with eyes closed with 2 trails of each test and a five-
Chennai. There were 100 children in the age group minute rest was provided between successive trials. The
of best trial was documented. Children were instructed
8-10 years old. After getting informed consent signed, to stand on the force platform with the dominant leg
all children were evaluated using Body Coordination exactly placed on the reference marking of foot in the
Test for children - BCTC. Initially at the baseline all the force platform. Before making the children to stand
100 children were evaluated with MABC. It was found on
that 20 children out of the total number of 100 children
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 69
the force platform, the dominant leg assessment was Motor skills and balance were still improving till the
made by making the children to kick a ball which has age of 8, to avoid the bias in balance control and motor
been suddenly rolled before him without any performance in younger children, the age group selected
instructions on which leg to be used for kicking with the in this study is 8 to 10 years of age, and the primary
simple instruction like “kick the ball hard”. Time in finding of the current research was COP Excursion
seconds has been recorded and 2 trial has been allowed was decreased in children with DCD. The reduction of
with the baseline familiarization test for 5 minutes. ability to maintain balance has been well documented in
children’s with DCD. TABLE 1 show that children with
A computer program in the pressure platform was
DCD have greater postural sway as compared to non-
used to analyze and document peak-to-peak amplitude
DCD children. This observation was done with closed
and standard deviation of the COP from the mean value
eyes in children with DCD during balance testing.
of COP in mm, denoted as sway amplitude. In the same
Proprioceptors play a major role in maintaining balance
way double leg stance time the sway was calculated. The
control rather than on visual afferent impulse.
trial has been repeated by making the child to close their
eyes during single leg stance and double leg stance and DCD children have immediate adverse effects on
their ability to balance has been assessed. academic and daily living skills because of balance
disorder and have significant impacts on academic,
Data Analysis psycho-social and vocational outcomes.

Table 1: Peak-to-peak amplitude of the center of Conclusion

pressure (cop) displacement (copmax) and standard
Children with DCD physically, psychologically and
deviation of the cop (copsd) in the anterior posterior
socially avoid participating in physical activities in order
(a/p) and in mediolateral (m/l) direction
to avoid injuries due to their difficulty in balance. Thus,
Balance Test Group A Group B early identification and treatment of balance control
Double Leg Stance with Closed Eyes (mm) difficulties are in increasing need.
CoP max -M/L 25.00 ± 9.90 10.11 ± 2.00
Ethical Clearance: Has been obtained from institutional
CoP sd -M/L 4.20 ± 1.00 2.00 ± .00
CoP max-A/P 15.20 ± 3.30 10.44 ± 2.00 ethical committee
CoP sd-A/P 4.00 ± 2.00 2.01 ± .00
Conflict of Interest: Nil
One Leg Stance with Closed Eyes (mm)
CoP max -M/L 40.67 ± 0.80 20.00 ± 2.00 Source of Funding: Nil
CoP sd -M/L 15.00 ± 2.00 4.11 ± 1.00
CoP max-A/P 40.00 ± 7.00 28.20 ± 4.00 REFERENCES
CoP sd-A/P 9.15 ± 1.00 5.52 ± 1.00
1. GanapathySankar U, Saritha S. A study of
prevalence of Developmental Coordination
Discussion
Disorder (DCD) at Kattankulathur, Chennai,
The present study examined the movement Indian Journal of Physiotherapy and occupational
difficulties in children with DCD and to examine the therapy, 2011, Jan;5(1).
balance ability between children with Developmental 2. Dr. U. Ganapathy Sankar, the Prevalence
Coordination Disorder (DCD) and NON-DCD Group. of Developmental Coordination Disorder at
The Body Coordination Test for Children was used Kattupakkam, Tamilnadu. IOSR Journal of
in this study since the test examines the assessment Pharmacy, Volume 8, Issue 2 2018, PP. 49-52
of children’s coordinative performance. The results 2018
showed that children participating in this study exhibited
difficulty in balance along with the motor coordination 3. Nicolson, R. I., Fawcett, A. J., & Dean, P.
difficulty indicating the existence of DCD disorder. Developmental dyslexia: The cerebellar deficit
hypothesis. Trends in Neurosciences, (2001).
24,
508–511, Commentaries pp. 512–516.
70 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

4. Odenrick, P., & Sandstedt, P. Development 7. Raynor, A. J. (1998). Fractioned reflex and
of postural sway in the normal child. Human reaction time in children with developmental
Neurobiology,1984, 241–244. coordination disorder. Motor Control, 2, 114–124.
5. Piek, J. P., & Coleman-Carman, R. (1995). 8. Raynor, A. J. (2001). Strength, power, and
Kinaesthetic sensitivity and motor performance coactivation in children with developmental
of children with developmental co-ordination coordination disorder. Developmental Medicine
disorder. Developmental Medicine and Child and Child Neurology, 43, 676–684.
Neurology, 37, 976–984.
9. Riach, C. L., & Hayes, K. C. (1987). Maturation
6. Piek, J. P., & Skinner, R. A. (1999). Timing and of postural sway in young children.
force control during a sequential tapping task in Developmetnal Medicine and Child Neurology,
children with and without motor coordination 29, 650–658.
problems. Journal of the International
10. Roncevalles,M. N. C., Jensen, J. L., &Woollacott,
Neuropsychology Society,5, 320–329.
M. H. (2001). Development of lower extremity
kinetics for balance control in infants and young
children. Journal of Motor Behavior, 33, 180–192.
DOI Number: 10.5958/0976-5506.2019.01539.0

A Comparative Study to Determine the Effectiveness of

the Taping and Mulligan’s Mobilization with Movement
Techniques on Pain in Knee Osteoarthritis

Balaji R. Pawar1, A. Jeganathan2, R. Monisha3

1
Student Bachelor of Physiotherapy, 2Specialist Physiotherapy Practitioner, Cambridgeshire and
Peterborough Nhs Trust, 3Assistant Professor, SRM College of
Physiotherapy, SRM Institute of Science and Technology, Chennai

ABSTRACT
Background: There is no cure for knee OA, thus conservative treatment aims to reduce pain and limit
functional impairment. Inexpensive Non pharmacological, non-surgical interventions with minimal side
effect are desirable. Such as the treatment offered by physiotherapists, there are recommended as the first
line of treatment for hip and knee osteoarthritis (OA)
Methodology: 20 Patients took for the research study, they divided into two groups. Group A-10 Patients
has given McConnell Patella taping, Group B-10 patients has given mobilization with movement, For both
the groups each treatment session may last for 15-20minutes 4 days a week.
Result: As the results indicate, there was statistical significant effects following two techniques i.e. MWM
and taping on pain in OA knee patients. Group A (MWM) shows the pre treatment mean of vas 6.1 and
post treatment mean value is 2.2. the difference between pre and post treatment is 3.9 with p value <0.0001
i.e. significant
Conclusion: The study also emphasis that mobilization with movement is comparatively more beneficial in
reducing pain than taping in OA knee patients

Keywords: Osteoarthritis, MWM, McConnell patella taping

Introduction considered a ‘wear and tear’ process, where there is a
gradual degradation of the hyaline cartilage that covers
Life is movement, and movement is life. Live
the articulating surfaces of the bones in the knee joint.
movements takes place at joints. Arthritis hampers joint
It is regarded as the important socioeconomic problem
movement and disturbs normal life. Osteoarthritis, is
because it is one of the foremost disabling conditions and
a joint disorder and most common form of arthritis, it
its treatment entails great expenditures
is a deliberating progressive disease affecting 20% of
the population, principally the elderly1. The commonly The high incidence of knee osteoarthritis in India
affected joints are knees, hips, spine and shoulder. Knee is the result of its prevalence among women who fall
osteoarthritis is a degenerative disease of the knee joint victim to it2. Menopausal women are especially prone to
more common in people older than 40 years it. Till the age of 55 it occurs equally in both the sexes;
predominately after 55 the incidence is higher in women. It is estimated
that approximately four out of 100 people are affected.
The incidence of knee osteoarthritis in India is as high as
12 Per cent. Factors such as age, family history, obesity
Corresponding Author: increase susceptibility to OA. In addition to these, local
A. Jeggannathan biomechanical factors like congenital anomalies, trauma,
Specialist Physiotherapy Practitioner, and occupational injuries affect the occurrence and
Cambridgeshire and Peterborough Nhs Trust localization of OA. Symptomatically, the most common
Email: [email protected]
72 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 72

affected joint in OA is the knee joint3.Old age cannot Patellar taping was invented by jenny McConnell, a
be healed or prevented. The common clinical features of physiotherapist. This intervention involves pushing the
knee osteoarthritis are pain stiffness and decreased range patella medially and securing it in this position with tape
of motion. The commonest obstacle for the elderly to on the skin/ The acute effects of taping the knee as short
carry out ADL is the problem of joint pain and term or intermittent treatment for knee pain is believed to
decreased mobility. relieve pain by improving alignment of the
patellofemoral joint and/or unloading inflamed soft
tissues.
Changes in Osteo-Arthritic Knee
Benefits of Patella Taping: When used correctly,
Joint Space Narrowing: Osteoarthritis causes patella tapping techniques can; decrease pain during
deterioration of the joint structures, deterioration of sport or activity aid healing of certain knee injuries,
articular cartilage leads to narrowing of the joint space correct patella alignment , allow an earlier return to
(i.e., the space between the end of bones in a joint). sport or activity following injury , reduce the likelihood
Progressively smaller joint space suggests worsening of injury aggravation, prevent knee injuries (such as a
of osteoarthritis. Joint space loss is usually not uniform dislocated patella) during high risk of sports (such as
within the joint. basketball, football etc.,)

Development of Osteophytes: Osteophytes , also

Objective of the Study
called bone spurs, are protrusions of bone and cartilage.
The bony projections are commonly seen in areas To study the effect of McConnell patella taping
of a degenerating joint and can be seen on x-rays. on
Osteophytes, Which typically develop as a reparative pain in knee osteoarthritis.
response by remaining cartilage, cause pain and limited
To study the effect of Mobilization with movements
range of motion in the affected joint
on pain in knee osteoarthritis.
Ligamentous Instability: Anterior cruciate ligament,
To compare the effect of McConnell patella tapping
posterior cruciate ligament, Medial collateral ligament , and mobilization with movements on pain in knee
Lateral collateral ligament arthritis.
Subchondral Cyst Formation: Subchondral cysts are Need of Study: Application of mulligan’s mobilization
fluid-filled sacs which extrude from the joint. The cysts with movement techniques produced immediate pain
contain thickened joint material, mostly hyaluronic relief after first treatment procedures thus MWM have
acid, Traumatized subchondral bone undergoes cystic been found to be feasible and efficacious in individuals
degeneration. with knee osteoarthritis. Taping has been proved cheap
and effective method of treatment on pain in knee
There is no cure for knee OA, thus conservative osteoarthritis. Taping and MWM techniques compared
treatment aims to reduce pain and limit functional in this study for their effectiveness for treating patients
impairment. Inexpensive Non pharmacological, with knee osteoarthritis5.
non surgical interventions with minimal side effect
are desirable. Such as the treatment offered by Material and Methodology
physiotherapists, there are recommended as the first
line of treatment for hip and knee osteoarthritis(OA). Sample Size: The samples of the study will consist of
Given the prevalence of knee OA, its economic and 20
human burden, and accumulating evidence supporting patients with knee joint osteoarthritis
the effectiveness of various physiotherapy interventions Sampling Technique: Simple random technique is
for patients with knee OA of the hip or knee, further used
research is warranted4. Two common forms of
physiotherapy intervention are patellar tapping and Population: The population for this study includes
mulligan mobilization with movement recommended by all
subjects having osteoarthritis of knee.
international bodies
Sample Selection
73 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 73
Inclusion Criteria: knee pain, age 50 years , body mass
index 38, crepitus, bony tenderness , bony enlargement ,
no palpable warmth
Exclusion Criteria: Allergy to tape, secondary arthritis and a foam roller or rolled up towel under the knee. Start
of kne or inflammatory condition like rheumatoid the tape in line with the middle of the knee cap at the
arthritis, outer aspect of the knee. Using your thumb on top of the
tape, gently push the knee cap towards the inner aspect
Body mass index 38( owing to difficulties of taping
of the knee whilst simultaneously using your fingers to
the knee effectively). Active infection around knee
pull the skin at the inner aspect of the knee towards the
joint, patients who underwent knee surgery (previous 6
knee cap. Finish this taping technique at the inner aspect
months), psychological problems.
of the knee ensuring you have created some wrinkling
Outcome Measures: Pain and functional disability of the skin at the inner aspects of the knee . repeat this
process 1 – 3 times depending on the amount of support
Measuring Tools: VAS (VISUAL ANALOG SCALE); required6.
Knee pain is recorded with VAS before and after each
tape application and mobilization with movement. Removing The Tape: Care should be taken when
removing the tape to avoid injury aggravation or skin
Methodology damage. The tape should be removed slowly, pulling the
tape back on itself with pressure placed on the skin as
Treatment Protocol: 20 Patients took for the research
close as possible to the line of attachment of the tape.
study, they divided into two groups. Group A-10
Patients has given McConnell Patella taping, Group Mulligan’s Mobilization With Movement (MWM)
B-10 patients has given mobilization with movement,
For Knee: The patient is in standing position and s
For both the groups each treatment session may last for
asked to place the painful leg on the chair. The therapist
15-20minutes 4 days a week.
then places his hands proximally around the lower leg
Before starting the study process all participants are and rotates the tibia medially and hand on the fibular
informed with the study in general and the study aims side carries the fibula forward at the same time.
and objectives. Consent forms and pre study information
sustaining this rotation the patient is asked to forward
sheet has given to them prior to the study. The subjects
flex his knee provided there is no pain.
have been randomly assigned to one of the two groups
either the experimental group or control group. The
participants were blind to which group they enrolled to. Results and Statistical Analysis

At the first session, before giving the treatment

Table 1: Gender Distribution in the Sample Size
demographic information was taken after that the
Selected
participant was asked to use VAS to assess pain. Group
A, was given therapeutic knee taping (patella taping) Group No. of Male No. of Females
and Group B, was given mulligan’s mobilization with Group No. of Male No. of Females
movement (MWM) for the knee. MWM 6 4
Taping 7 3
Taping Procedure: Patient is seated in a
comfortable Total 13 7
position usually supine at an optimal working height
.The skin should be cleaned and dried, removing any Table 2: Showing Mean of The Pre and Post
grease of sweat. Full attention of patient is demanded. Vas
The joint is place in a functional position with Measures of Mobilization with Movement and
minimum stress on the joint. It is ensured that the Taping
PRE Post
ligaments are in shortened position. The patient is Difference
Groups (mean +/- (mean +/-
explained about the function of the tape and how (mean +/-S.D)
S.D) S.D)
it feels. MWM 6.1+/-1.595 2.2+/-1.033 3.9+/-1.524
McConnell Patella taping –Begin lying on your Taping 5.3+/-1.337 2.6+/-1.114 2.7+/-1.059
back, with the knee slightly bent, but completely relaxed P Value <0.0001 0.0001 0.0558
Discussion As the results indicate, there was statistical
significant effects following two techniques i.e. MWM
Many studies have been carried out to determine the
and taping on pain in OA knee patients. Group A
effect of mulligan’s mobilization with movement and (MWM) shows the pre treatment mean of vas 6.1 and
patellar taping on various joints. Although this topic is post treatment mean value is 2.2. the difference between
widely discussed in earlier studies, the results obtained pre and post treatment is 3.9 with p value <0.0001 i.e.
vary in most of the studies both the techniques have significant
been proved beneficial in decreasing pain in
osteoarthritis. While taping shows pre treatment mean value of vas
5.3 and post treatment mean value is 2.6. The difference
The current study was undertaken to investigate between pre and post treatment is 2.7 with p value
and compare the effectiveness of the mobilization 0.0558
with movement and taping in knee osteoarthritis
Statistical analysis shows that mobilization with
patients Evgeniya Dimitrova ct al. (2008) conducted a
movement technique is more effective than taping.
study to provide evidence based recommendations for
prescription of mobilization with movement. This study
demonstrated that strengthening of knee musculature Conclusion
was more effective after the MWM and was associated Based on statistical analysis, its interpretation
with significant improvement in quadriceps strength and and evidence in the present study strongly emphasis
function, when compared with controls in reducing pain that mobilization with movement and taping both are
and improving function in individuals diagnosed with significantly effective in reducing pain in OA knee
knee osteoarthritis, Wayne Hing ct al. (2006) conducted patients.
a stud to evaluate the overall efficacy of MWMs7. This
study found significant positive results with MWM The study also emphasis that mobilization with
applications, when compared to placebo or control movement is comparatively more beneficial in reducing
groups. The most common significant results found were pain than taping in OA knee patients.
increase in strength reduction in pain levels and increase Clinical Implications: The study suggest there is
in pain pressure threshold and Cushnaghan ct al (1994) significant difference between in the effects of both
conducted a study to test the hypothesis that medial the techniques thus more beneficial technique i.e.
taping of the patella reduces the symptoms of Mobilization with movement may be used in the
osteoarthritis of the knee when the patella-femoral joint treatment of knee OA.
is affected. The aims of this study were firstly, to
evaluate the symptomatic benefit of knee taping Mobilization with movement may be used to
designed to realign the patella in older subjects with decrease the pain in knee in osteoarthritis patients and
knee osteoarthritis and secondly to apply rigorous improve the quality of life in OA knee patients
clinical trail methodology to a physical form of Limitations: The study was conducted in a small
treatment8. group of population so cannot be generalized to whole
population and large study is required
For the purpose of the study 20 patients were taken
which divided in two even groups. 10 patients were Ethical Clearance: Taken from institutional ethical
given McConnell Patella Taping and 10 patients were committee
given mobilization with movement. VAS was taken pre
and post treatment to assess the pain. For both the Source of Funding: Nil
groups each treatment session last for 15-20minutes 4
Conflict of Interest: Nil
days a week.

Study included 13 male patients and 7 female REFERENCES

patients out of 20 patients chosen for experiment. In 1. J. R. Roush, R. Curtis Bay Prevalence of anterior
group A, no. of male patients were 7 & no. of female knee pain in 18-35 year-old females Int J Sports
patients were 3. In group B,6 patients were male & 4 Phys Ther, 7 (4) (2012), pp. 396-401
patients were females.
2. S. Werner Anterior knee pain: an update of 6. S. J. Warden, R. S. Hinman, M. A. Watson, K.
physical therapy, Knee Surg Sports Traumatol G. Avin, A. E. Bialocerkowski, K. M. Crossley
Arthrosc, 22 (10) (2014), pp. 2286-2294 Patellar taping and bracing for the treatment of
3. M. Boling, D. Padua, S. Marshall, K. Guskiewicz, chronic knee pain: a systematic review and meta-
S. Pyne, A. Beutler Gender differences in the analysis- Arthritis Care Res, 59 (1) (2008), pp. 73-83
incidence and prevalence of patellofemoral pain 7. K. Crossley, K. Bennell, S. Green, S. Cowan, J.
syndrome, Scand J Med Sci Sports, 20 (5) (2010), Mc Connell Physical therapy for patellofemoral
pp. 725-730 pain a randomized, double-blinded, placebo-
4. J. P. Fulkerson Diagnosis and treatment of controlled trial-Am J Sports Med, 30 (6) (2002),
patients with patellofemoral pain, Am J Sports pp. 857-865
Med, 30 (3) (2002), pp. 447-456 8. D. Hryvniak, E. Magrum, R. Wilder
5. V. Sanchis-AlfonsoAnterior Knee Pain and Patellofemoral pain syndrome: an update- Curr
Patellar Instability, Springer-Verlag London Phys Med Rehabil Rep, 2 (1) (2014), pp. 16-24
Limited (2011)
DOI Number: 10.5958/0976-5506.2019.01540.7

Perception of Undergraduates and Postgraduates of the Scope

of Periodontics

F. Mariyam Niyas1, Radhika Arjunkumar2

1
Graduate Student, 2Reader, Department of Periodontics, Saveetha Dental College,
Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai,
India

ABSTRACT
Background and Aim: Periodontology is a fast evolving field where newer insights into existing concepts
are changing the face of the traditional periodontal treatment. Constant research is taking place so as to
develop a number of newer avenues in the treatment of the periodontal diseases. However, the protocol
of management of periodontal diseases in the setup of general dental practice has undergone little change
over the last decade. How do dental professionals view the scope of the specialty of periodontology?
The aim of this study is to use a rank-order survey to determine the scope of periodontology according to
undergraduates and postgraduates.
Method and Materials: Based on a previous study in which respondents were asked to list the answers
to the question, ‘‘Who is a Periodontist?’’ The results were consolidated into eight statements. The eight
statements were placed into a rank-order online survey. The responses primarily came from undergraduate
dental students, interns, general dental practitioners and postgraduates of various departments.
Result: Undergraduates defined the scope of this practice by stating that the two most important aspects are
surgical treatment of periodontitis and promotion of research towards better understanding of periodontal
health and its relation with systemic diseases. The least important statement was that ‘‘Periodontists are
educators promoting health.’’ Postgraduates perceive the specialty of periodontology differently than
undergraduates in that they ranked surgical treatment and the esthetic surgical procedures as the two most
important.
Conclusion: This study shows that there are differences between the two groups of respondents. With the
information shown here, communication with a periodontist regarding their scope in the field, both
undergraduates and postgraduates of other specialties will become knowledgeable and have a high diagnostic
acuity.

Keywords: Undergraduates; Postgraduates; Data analysis; Esthetics, Implant, Periodontics

Introduction given periodontal diagnosis and treatment a level of
predictability of success, which was lacking just a
The specialty of Periodontology is evolving in all
decade ago. Quality dental institutes, which incorporate
aspects ranging from newer advances in diagnosis, to
all these advances in their setup and curriculum, have
the use of growth factors and regenerative techniques
evolved all over the country. Thus, today we see
in treatment. These evidence-based advances have
periodontology as a specialty reaching newer heights,
and with a very bright future in front of it.
Corresponding Author: Historically periodontal therapy has been directed
Radhika Arjunkumar primarily at the elimination of disease and maintenance
Reader, Department of Periodontics, of a functional, healthy dentition and supporting tissues.
Saveetha Dental College, More recently however it has become increasingly
Saveetha Institute of Medical and Technical Sciences focused on esthetic outcomes, which extend beyond
Saveetha University, Chennai-600077, Tamil Nadu, tooth replacement and tooth color to include the soft
India Phone: +919884281681 tissues framing the dentition. [1, 2]
Email: [email protected]
77 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 77

In spite of the developing of quality dental human bone that exponentially increased the success rate
[4]
institutes, a majority of the population visits private of dental implants. Today, dental implants have become
dental clinics for their dental needs, especially in the a major part of the periodontist’s armamentarium.
urban areas. The development of Internet as a reliable
source of knowledge, and the publication of quality In an International Journal of Periodontics &
journals has made knowledge of periodontal treatment Restorative Dentistry guest editorial dated September/
freely accessible to all practicing dentists. However, October 2008, entitled ‘‘Where is periodontology
Periodontists commonly complain that the knowledge heading?’’ the author’s dilemma of ‘‘moving away from [11]

of periodontal diagnosis and treatment in the minds of a our primary professional competencies’’ is discussed.
general dentist is sometimes limited to the level taught Is periodontology transitioning toward dental implants
in the BDS curriculum at the time of their graduation. and implant-related procedures as a prime focus for
practice rather than as a subcategory of the overarching
How is the practice of periodontology defined? core ideals of creating and maintaining a clinically
In today’s world, a Periodontist a dentist whose prime healthy periodontium with the natural dentition? This
therapeutic focus is to help to preserve natural teeth in thought was also stated in 2007 in the preface of Edward
health, or is the prime focus replacing the natural teeth Cohen’s atlas, in which, regarding dental implants, he
with esthetically pleasing and functional implants? stated, ‘‘Too often teeth are now prematurely
extracted [12, 13]
Should specialists in Periodontology increase time for implant placement.’’ . Case study by Ramesh
and et al [14]
reports placement of implants in generalized
attention toward the research and techniques of dental aggressive periodontitis where the esthetics and
implants and ridge preservation/ augmentation, and functions had to be restored. After 4 months of
thus chance the dilution of periodontal research for the placement, the radiographs showed successful
natural dentition? osseointegration of the dental implants without any
biological complications. Such cases are primarily
The contrast from the origins of the specialty of handled and followed –up by Periodontists for better
Periodontology in 1947 to today is noteworthy. In treatment outcome.
describing the responsibility and the scope of practice of
Periodontics, the American Academy of Periodontology Because of the dynamic history of periodontology
(AAP) presently states: and the innovations that have occurred, what is the scope
of today’s periodontist? The purpose of this research
A Periodontist is a dentist who specializes in the
project is to demonstrate how undergraduates and
prevention, diagnosis, and treatment of periodontal
postgraduates view the specialty.
disease, and in the placement of dental implants.
Periodontists are also experts in the treatment of oral
inflammation. Periodontists receive extensive training Materials and Method
in these areas, in the three additional years of education
beyond dental school. They are familiar with the latest Based on a pilot study conducted Dr. Paul A. Levi
techniques for diagnosing and treating periodontal Jr., [3] Department of Periodontology, Tufts University
disease, and are also trained in performing cosmetic School of Dental Medicine in which respondents were
periodontal procedures [3]. asked to list the answers to the question, ‘‘What is a
periodontist?’’ the results obtained were consolidated into
However, replacing missing teeth has always been eight statements. The eight statements were placed into
a concern for dentists, and doing so through dental an anonymous rank-order online survey. The link to the
implantology is not a new phenomenon. History has survey form was delivered to the respondents in digital
evidence of Egyptians and Mayans implanting sea- form using an online survey program. The
[4, 5, 6, 7]

respondents
shells and the Romans using metal implants were able to open the link on their mobile devices
as and
replacements for lost teeth. [8] In the early 20th century, fill in the survey at location of comfort. The
[9]
responses
E.J. Greenfield used a dental implant similar to primarily came from undergraduate dental students,
78 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 78
those later used by Branemark et al. in the mid- interns, general dental practitioners and postgraduates
20th
[10]
century. However, it was the discovery of of various departments. All participants were advised
titanium’s of
biocompatibility and ability to osseointegrate with the nature of the study and consented to respond.
The
responses were gathered from online forum and tabulated Statement 4: Periodontists are advisors to other dental
and maintained in a secure file on a PC. and medical professionals in regards to diagnosis,
prognosis and treatment planning
The definitions returned from the pilot were
categorized into the following themes: implants, Statement 5: Periodontists are educators promoting
education, advising, cosmetics, research, surgery, oral health
hygiene, and co-therapists with other professionals. One
sentence was created for each theme. These sentences Statement 6: Periodontists treatments help general
were then labeled as statements and placed into a rank- dentists and other specialists increase successful
order survey, which was then distributed, in digital form therapeutic outcomes with their patients
using an online survey program to widen distribution to
undergraduates and postgraduates. The online survey Statement 7: Periodontists assist in conserving patient’s
ensured that all eight statements were ranked to dentition in health by emphasizing the patient’s oral
complete the survey. Information collected along with hygiene plaque control
the survey responses included: 1) Name; 2) Email
Statement 8: Periodontists treat esthetically
address; 3) Designation; 4) Department; 5) Gender.
compromised periodontal conditions through bone and
Inclusive criteria: Dental students, interns, general soft tissue (gum) procedures
dental practitioners, post-graduate students, post-
graduate practitioners were included in the study. Data Analyses

Exclusive criteria: Dental technicians, dental assistants, In total, 100 responses were received, and the
dental hygienists, persons of other medical profession, information was compiled from the occupation
patients were excluded from the study. variables to establish two general cohorts of responders:
undergraduates (general practitioners, dental students),
Survey response collection was terminated when the
and postgraduates (which includes other specialists
two main groups of respondents from Saveetha Dental
including periodontologists).
College, undergraduates(65%) and post-graduates(35%),
had provided 100 responses. Descriptive analyses included frequencies and
graphical outputs were obtained. The major cohorts
Online Survey form were compared using manual data analysis to evaluate
whether the rank order was different between the two
Name: groups for a specific statement.
Email address:
Results
Designation:
The rank order of the Periodontists’ responses
Department: shows that statement 2, ‘‘Periodontists surgically treat
advanced gum and bone infection problems (36%),’’
Gender:
was considered the most important statement expressing
Who is a Periodontist? (Rank the statements in order the scope of periodontics by undergraduates. Statements
o relevance) 3 and 8, i.e., “Periodontists promote research to better
understand periodontal disease, their effect on systemic
Statement 1: Periodontists perform dental implants and health and their related therapies” and “Periodontists
related procedures treat esthetically compromised periodontal conditions
through bone and soft tissue (gum) procedures” were
Statement 2: Periodontists surgically treat advanced
the second and third most relevant statements to the
gum and bone infection problems
undergraduate students. The least relevant statement
Statement 3: Periodontists promote research to better was found to be statement 1 and 5, that is, “Periodontists
understand periodontal disease, their effect on systemic perform dental implants and related procedures” and
health and their related therapies “Periodontists are educators promoting health”.
Postgraduates defined their scope of periodontics
by stating that the most important aspect is
statement
2, which states, “Periodontists surgically treat advanced
gum and bone infection problems”. The second and
third most relevant points to them is statement 8, which
states “Periodontists treat esthetically compromised
periodontal conditions through bone and soft tissue
(gum) procedures” and “Periodontists perform dental
implants and related procedures. The least relevant Graph 3: Third rank given by Undergraduates and
statement was “Periodontists are educators promoting Postgraduates
health”. The results have been graphically represented
form graph 1 to 8

Graph 4: Fourth rank given by Undergraduates and

Postgraduates

Graph 1: First Rank Given by Undergraduates and

Postgraduates

Graph 5: Fifth rank given by Undergraduates and

Postgraduates

Graph 2: Second rank given by Undergraduates and

Postgraduates

Graph 6: Sixth rank given by Undergraduates and

Postgraduates
because all dentists refer patients to Periodontists to
have periodontal surgery; hence these results are not
surprising. Along the same lines, both undergraduates
and postgraduates of all specialties leave surgical
periodontal therapy to the Periodontists. This also
indicates that both undergraduates and postgraduates
have a broad perception of the primary scope of
periodontology.

In the past decade advances in implant surface

technology and continuous clinical research have
Graph 7: Seventh rank given by Undergraduates provided clinicians with innovative and efficient
and Postgraduates operative protocols for properly treating increasingly
demanding clinical situations.[16]

The statements “Periodontists promote research

to better understand periodontal disease, their effect
on systemic health and their related therapies”
and “Periodontists treat esthetically compromised
periodontal conditions through bone and soft tissue
(gum) procedures” were the second and third most
relevant statements to the undergraduate students. This
again indicates the importance given by undergraduates
to the scope of periodontology with regards correlation
of systemic health with periodontal health and in the
Graph 8: Eighth rank given by Undergraduates and growing field of esthetic dentistry.
Postgraduates The least relevant statement was found to be
statements were, “Periodontists perform dental implants
Discussion and related procedures” and “Periodontists are educators
promoting health”. This is a significant finding as it
The previously conducted study asked the
indicates a lack of awareness amongst undergraduates
respondents to list answers to the question ‘‘Who is a
regarding the scope of periodontology in the field of
Periodontist?’’ and eight statements were compiled. All
implantology. Periodontists are the primary health
of the statements are important regarding the scope of
advisors when it comes to maintenance of oral hygiene
the specialty; however, the purpose of this study is to
and undergraduates seem to have overlooked the role
determine how current-day undergraduates view the
played by a periodontist in preventive therapy.
specialty of periodontology and how postgraduates view
the specialty. [15] Among postgraduates, the second most important
statement was considered to be “Periodontists treat
In total, 100 responses were received, and the
esthetically compromised periodontal conditions
information was compiled from the occupation
through bone and soft tissue (gum) procedures” again
variables to establish two general cohorts of responders:
giving importance to the scope of periodontics in
undergraduates (general practitioners, dental students),
esthetic dentistry.
and postgraduates (which includes other specialists
including periodontologists). The second and third most relevant points to them is
statement 8, which states “Periodontists treat
Both groups of respondents ranked the statement
esthetically compromised periodontal conditions
“Periodontists surgically treat advanced gum and
through bone and soft tissue (gum) procedures” and
bone infection problems” the most important. This
“Periodontists perform dental implants and related
is
procedures. So here
we can see how postgradutes are more aware of the role This study shows that there are differences between
of a periodontist in the placement of implants. The least the two cohorts. With the information shown here,
relevant statement was “Periodontists are educators periodontal care by Periodontists can be specifically
promoting health”. targeted to better serve patients and referring dental
health professionals.
Thus, it appears that postgraduates feel that next
to surgically treating periodontal infection, placing Ethical Clearance: Clearance from the Institutional
implants and doing implant associated osseous ethical committee was obtained.
augmentation procedures is third most important in their
scope of practice. Source of Funding: Self

The survey provides insight into how Conflict of Interest: Nil

undergraduates define the scope of this specialty and
how the postgraduates perceive it. The overwhelming REFERENCES
accord is that all cohorts feel that the most important
aspect of the Periodontists is to surgically treat 1. Murugan Thamaraiselvan, Sugumari Elavarasu,
advanced gum and bone problems. Thangavelu Arthie. Comaprative Evaluation of
coronally advanced flap with or without platelet
There are limitations to this study in that the rich fibrin membrane in the treatment of isolated
interpretation of each statement is related to individual gingival recession. J Ind. Soc. Periodontology
perceptions, which is influenced by training and 2015; 19(1); 66-71
experience. A similar study by physicians specializing
2. Kontovazainitis G, Griffin TJ, Cheung WS.
in HIV found that their convenience sample could not
necessarily be generalized to all physicians providing Treatment of gingival recession using platelet
HIV care. The present study had a similar limitation. concentrate with a bioabsorbable membrane and
In addition, the results are limited by the nature of self- coronally advanced flap: A report of two cases.
reported data just as the data were in the HIV–physician Int J Periodontics Restorative Dent. 2008;28:301–
study [17]. 7.
3. American Academy of Periodontology. What is a
Going forward, it would be interesting to see if
periodontist? Available at: http://www.perio.org/
there were further differences if a wider population of
consumer/periodontist2.htm. Accessed May 27,
undergraduates and postgraduates were used.
2013.

Conclusion 4. Langer B, Langer L. Subepithelial connective

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stating that the two most important aspects are surgical
5. Harris RJ. A short-term and long-term comparison
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its relation with systemic diseases. The least important matrix and a subepithelial graft. J Periodontol
statement was that ‘‘Periodontists are educators 2004;75:734-743.
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ranked surgical treatment and the esthetic surgical
7. Rudy RJ, Levi PA, Bonacci FJ, Weisgold AS,
procedures as the two most important. Communication
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by the periodontist to the general dentist is important to
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Meeting provides rare opportunity to examine Kaarthikeyan. Comprehensive rehabilitation
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DOI Number: 10.5958/0976-5506.2019.01541.9

Correlation between the Nature of Toothpaste and the

Prevalence of Brushing Habits of Children Residing in Chennai

Rinieshah Nair R. Baskran1, Deepa Gurunathan2, Madhusudhan Vasantharajan3

Graduate Student, 2Professor, 3Senior Lecturer, Department of Pedodontics and Preventive
1

Dentistry, Saveetha Dental College, Saveetha University, Saveetha Institute of Medical and Technical
Sciences, Chennai, India

ABSTRACT
Aim: To correlate the nature of toothpaste used to the brushing habits of children in Chennai. Objective:
To assess the preference of children in relation to the type of toothpaste used by them. Background: A
number of factors should be taken into account when designing toothpaste formulations for
children at the different stages of their development. They all contribute to the formation of brushing habits
of children. An ideal children’s toothpaste formulation should maximise fluoride availability, along with
the levels and types of surfactant that will decrease the interference with a child-friendly, pleasant brushing
experience. The ultimate goal is to maximise the compliance by providing a more pleasurable brushing
experience and oral health benefits.
Reason: To deliberate the nature of the tooth paste in correlation with the brushing habits of children in
chennai.
Keywords: toothpaste, nature, content, children, brushing habits, oral health.
Introduction Dentists’ best efforts to effectively educate their
paediatric patients to brush their teeth are only as good
Dental care has consistently persevered to improve
as the products introduced. In this case, toothpaste
the quality of dental health among the public. On the
has become the light of the subject at hand(6,7,8). The
contrary however, children do not really grasp the
uncertain nature of the toothpaste used can waver the
importance of a well taken cared of dentition. (1)
child’s perception towards maintaining a positive
Children find brushing their teeth on a regular basis, a
attitude in sustaining a healthy environment in the oral
cumbersome task. Furthermore, using an oral hygiene
cavity(9,10,11,12). Parents also have an influence in proper
aid, commonly associated with toothpaste, to brush their
oral hygiene habits on their children. However, most
teeth can be challenging as children have unalterable
parents are barely even equipped with basic oral hygiene
preferences for whatever they put in their mouth(2,3,4,5).
habits and educate themselves only when the situation
turns grave.

Technology on the other hand is always improving.

People are always inventing something for the
Corresponding Author: betterment of their community. In the field of dentistry,
Deepa Gurunathan something as simple as toothpaste has rendered a huge
Professor, change in terms of oral hygiene. As time went, the
Department of Pedodontics and Preventive Dentistry, nature of toothpaste has been a major influence for the
Saveetha Dental College, Saveetha University, older generation as well as the new, especially children.
Saveetha Institute of Medical and Technical Sciences,
Chennai, India This research provides answers to whether the
Phone: +919790166987 nature of toothpaste in terms of taste(13), texture(14),
Email: [email protected] smell(15), appearance(16), colour(17), flavour(18), foam
production(19)
84 Indian Journal of Public HealthIndian
Research & Development,
Journal July Research
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 84

and cooling effect affects the tooth brushing habit among 100 school students. The students were randomly
of children(20). The queries are made into a set of 10 chosen, with ages ranging from the ages 9 to 12 years
questions and were distributed to school children old as the constant variable. An official letter was
between the ages of 7-12. The aim of this survey is to written to the principal of the schools contacted to aid us
correlate the nature of toothpaste to the brushing habits conduct the survey at their institution. Each student was
of children in Chennai. given one questionnaire, and was asked to answer the
questions honestly. The students were also informed that
Materials and Method if they were not able to understand the questions they
could ask and they would be given a verbal explanation.
A questionnaire consisting of a series of 10 The questionnaire was designed to provide adequate
questions was made based on the topic of this survey. information to successfully carry out this survey.
This survey was conducted to correlate the nature of The results obtained were then statistically tabulated
toothpaste with the brushing habits of children . It according to the questions asked. (Table 1)(Figure 1)
was conducted

Results

Table 1: The results obtained from the questionnaire were tabulated in the table below
No. Questions A B C
1. How often do you brush your teeth? 47 23 30
2. Do you use toothpaste to brush your teeth? 19 11 70
3. How much toothpaste do you use to brush your teeth? 0 33 67
4. What is your immediate response after brushing your teeth? 12 0 88
5. Do you brush your teeth under parental supervision? 40 50 10
6. Do you like the smell of your toothpaste? 78 12 10
7. Do you like the colour of your toothpaste? 68 22 10
8. Does the taste of your toothpaste affect your brushing? 10 20 70
9. Does your toothpaste taste sweet? 45 11 44
Does the advertisement for the toothpaste you are using affect your preference in
10. 50 35 15
toothpaste choice?

Figure 1: Correlation between the nature of toothpaste and the brushing habits of children in chennai
Table 1 shows 47 people chose option A which is neglect their children. Some parents are homemakers
that they brush their teeth once a day. 23 people brush but are unaware of the importance of brushing the teeth
their teeth twice a day. 19 people use toothpaste to brush of their children twice a day because they themselves do
their teeth while 70 of them occasionally use toothpaste not practice good oral hygiene habits. Ergo, the children
to brush their teeth. 67 people use toothpaste amounting do not comprehend that something as simple as brushing
to the full length of the tooth brush while 33 of them use their teeth can help them prevent various other health
it to only half the length of the toothbrush. 88 people problems that can relate to poor oral hygiene. Parents
gargle after brushing their teeth while only 12 of them should get themselves involved in their children’s health
spit it out without rinsing. 50 of them do not brush their and hygiene routine to ensure that they are on track.
teeth under parental supervision while 40 of them still
brush their teeth under parental supervision and 10 About 88% of the students gargle with water after
sometimes brush their teeth under parental supervision. brushing their teeth which is preferred as gargling cleans
the mouth even more after brushing. The suds formed
78 of them like the smell of their toothpaste, by the toothpaste will also be bothersome to the child as
12 of some toothpaste produce a lot of foam. However,
them do not like it while 10 of them do not even notice. another study showed that gargling after brushing
68 of them like the colour of their toothpaste, 22 of them increases the tendency to obtain caries on the teeth. The
do not like it while 10 do not even notice. 70 of them content of toothpaste, in general has fluoride which
are unaware that the taste of the toothbrush affects their basically helps strengthen the enamel of the teeth.
brushing habits, 20 of them disagree while only 10 agree
Gargling after brushing removes all the fluoride from
that the taste of the toothpaste affects their tooth
the teeth leaving only the fresh taste of toothpaste
brushing habits. 45 people use sweet toothpaste
without the needed function.
however, 44 of them do not even notice the taste of
their toothpaste and The sud that is formed is due to the presence of
10 of them do not use sweet tasting toothpaste. 50 Sodium Lauryl Sulphate (SLS), a chemical that causes
people are influenced by the advertisement used to foam and sud to form in any product(21). That chemical
advertise the toothpaste that they are currently suing to is responsible for the foam from the toothpaste during
brush their teeth. 35 of them disagree with the brushing. If the child does not prefer foam while
advertisement used to advertise their toothpaste so it brushing, then getting toothpaste with lesser SLS content
does not affect their preference in the toothpaste they will help boost the child’s interest in brushing their
use to brush their teeth and 15 of them are not aware. teeth.

In a nutshell, most of the children brush their teeth Colour, taste and smell may seem irrelevant when
once a day, and only sometimes use toothpaste to brush it comes to toothpaste but it actually plays a major role
their teeth. The amount of toothpaste used is the full- in ones toothbrushing habit especially children. As
length of the toothbrush. The immediate response after children, they are drawn to objects with a lot of colour
brushing their teeth is to gargle with water. The children
and vibrant animation. The toothpaste designed for
seldom brush their teeth under parental. They like the children should be colourful and striking to get more
smell of their toothpaste and are attracted to the colour
children to enjoy brushing their teeth as if it was a
of the toothpaste they use to brush their teeth. However,
leisurely activity. Toothpaste in general has a minty taste
they do not pay attention to the taste of their toothpaste.
and smell to allow the individual to feel fresh and clean
Most of them have toothpaste that tastes sweet. The after brushing their teeth. Children however have the
advertisement for the toothpaste they are using affects tendency to develop preference in these matters and
their preference in toothpaste choice while brushing have difficulty liking the mint flavour as it may be too
their teeth. strong. Therefore, it is only fair that toothpaste with a
variety of flavours is produced to increase the number of
Discussion children who will enjoy brushing their teeth. The colour
of the toothpaste may also help increase the child’s
The results obtained shows that the children brush preference in brushing their teeth. The probability of a
their teeth once with a reasonable amount of toothpaste child to brush his or her teeth with a toothpaste of their
everyday. This is because parents nowadays, tend to favourite colour, to a child brushing his with white-
leave home for work very early in the morning and coloured toothpaste is almost
too good to be true. Children often overcompensate studies have also determined that children use more
anything they can control. In this case, the amount of dentifrice when the product is a dentifrice flavoured for
toothpaste they use while brushing their teeth. Children children(24). In conclusion, there are many factors that
tend to think that more is better and ergo, they use a full- affect the brushing habits of the children. In this survey,
length of toothpaste to brush their teeth. It is up to the it is derived that children are highly influenced by the
parents to educate their children to control the amount nature of toothpaste especially children from a younger
of toothpaste used. The more the amount of toothpaste, age group. Ergo, it can be fairly understood that the
the higher the amount of foam and sud produced. That nature of toothpaste plays a vital role in the brushing
doesn’t necessarily mean that it is good for the teeth. habits of children.
Too much of anything will cause an adverse effect.
Based on this survey conducted, the nature of toothpaste Conflict of Interest: Nil
plays a major role in influencing the children to brush
Statement of Informed Consent: There was no need
their teeth. The colour, taste and smell all stimulate the
for any informed consent of the participant as there was
main senses allowing the child to be more attentive to
no personal information taken during this survey. The
the nature of the toothpaste, thereby increasing the usage
identity of the participants remain anonymous.
of toothpaste while brushing their teeth.
Statement of Human and Animal Rights: This
Based on a study conducted by Alex G. Stovell,
research was done in accordance with the ethical
Bernie M. Newton and Richard J. M. Lynch entitled
standards of Helsinki Declaration of 1975, as revised in
Important Consideration in the Development of
2000. No animals or humans were harmed in this
Toothpaste Formulation for Children(22), good oral
process.
hygiene habit can only be encouraged if the products
used are appealing. As the child ages, psychological Source of Funding: This research was self funded.
preferences for taste and smell, among other things
will start to develop. They tend to compartmentalise Ethical Clearance: Taken from International
Committee
the things they like and dislike. When they get used to
of Medical Journal Editors.
not brushing their teeth, it becomes a habit and habits,
good or bad, are hard to die. Hence, it is really important
to start at an early age. Children should be encouraged REFERENCES
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DOI Number: 10.5958/0976-5506.2019.01542.0

Effect of Structured Therapeutic Exercises Protocol on

Physical Functional Status in Women with Varying BMI

Ruchita R Shah1, S. Anandh2, G. Varadharajulu3

Faculty of Physiotherapy, 2Professor, Department of Community Health Science, 3Dean, Faculty
1

of
Physiotherapy, Krishna College of Physiotherapy, KIMS ‘Deemed to be’ University, Karad, Maharashtra,
India

ABSTRACT
Objectives: To find the effect of exercises on strength, endurance, flexibility and quality of life in women
with varying BMI.
Method: The study was conducted at physiotherapy department at Krishna Institute of Medical Sciences
Karad. A total 62 participants were includes and divided into 4 groups according to their BMI (underweight
(15), normal weight (15), overweight (17) and obese class I (15)). All groups were given same
strengthening exercises and stretching for upper and lower limb.
Result: Statistical analysis was done by parametric repeated measures ANOVA test. p values for Bench
press, Leg press, YMCA-Step test, Sit and reach test and SF-36 were calculated. While comparing the post
exercises values, the result revealed that in all the 4 groups there was significant improvement in strength,
flexibility and quality of life with p vale <0.0001 respectively. But for endurance there was significant
difference seen in group B with p value < 0.0147 and group C with p value <0.0001.
Conclusion: The study concluded that strengthening and stretching exercises has showed effect in
all 4
groups but more marked in group C.

Keywords: BMI, Strengthening exercises, stretching, Bench press, Leg press, YMCA-Step test, SF-
36.
Introduction According to recent report done in 2011
published
Over the years women are performing high by Census of India, it stated that from total
physically demanding tasks with increasing workforce population
and needs. Striving to achieve the goals they do not 48.43% were females, from these 16.96% females are
consider their well being along with fitness as a whole. between 30-40 years of age1.Women in India ignore
Females belong to full time working categories or physical fitness, only few women participate in fitness
freelance or farming along with their regular household exercises. A National Study of Physical activity pattern
duties. Their basic health requirement to combat against “Physical activity and inactivity patterns in India –
tiredness and musculoskeletal fitness plays a significant results from the ICMR-INDIAB study (Phase-1)”
conducted in four states Chandigarh, Jharkhand,
role to overcome their daily activities with ease.
Maharashtra and Tamilnadu it states that overall in
rural area (n=10054)
Corresponding Author: 59.6% females were inactive, and in urban area
Ruchita Rajendra Shah (n=
4173) 71.2% females are inactive. In Maharashtra from
MPT (Community Health Science),
rural area (n=2656) 56.8% females are inactive and in
Faculty of Physiotherapy,
urban area (n=1248) 68.5% females are inactive 2.
Krishna Institute of Medical Sciences
Deemed to be university, Health status of young and middle aged adult
Karad-415110, Maharashtra, India women to be targeted and perfect physical education is
Phone: 7066167727 important. Many physiological changes occur in human
Email: [email protected] body as we age. Maximum muscular strength and cross
sectional area is between the ages of 20-30 years. After
30 years physiological degenerative changes start, the
rate of these changes depends on the lifestyle of the
individual 3.
89 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 89

Components of health in relative to physical to any of the questions they were not included in the
fitness are strongly related to overall health which are study. Written informed consent form was taken and the
characterized by the capacity to carry out activities of whole study was explained to them. Inclusion criteria
daily living with physical strength and are strongly were as follows: (1) Age group 30-40 (2) Gender –
interrelated with lower prevalence of chronic diseases females (3) BMI categories from under weight to obese
and related risk factors 4. classification I. The exclusion criteria were as follows:
(1) Arthritic disorder (2) Hypertension or hypotension
Body mass index (BMI) is calculated simply by
(3) Hyperthyroidism or hypothyroidism (4) Cardiac
considering two components i.e. weight and height. BMI
condition (5) Diabetes mellitus (6) Surgeries undergone
is weight for height, weight in kilogram and height in
in past 6 months (7) Recent pregnancy.
square meters (kg/m2) 5, 6.
The nature of the study and intervention were
Muscular strength, endurance and power are
explained to the subjects and those who willing to
combined into single term “muscular fitness” and it participate were included in the study. A written consent
is considered as a vital part of taken as a whole health was taken from the subject. Then according to their BMI
related fitness based on quality and amount of exercises, they were be allotted in to the respective group.
to build up and maintain fitness 7.
Group A – less than 18.50 Kg/m2
Cardio respiratory fitness (CRF) is the capacity of
the vascular and pulmonary system through constant Group B – 18.50- 24.99 Kg/m2
physical activity to supply oxygen to the skeletal
Group C – 25- 29.99 Kg/m2
muscle8.
Group D – 30-34.99Kg/m2
Flexibility is the competence of the joint to
move Following therapeutic exercise protocol was
throughout the range of motion8. given
to all the groups, 4 times a week–
There is paucity of literature that shows the
relation of physical functions across varying BMI 1. Warm-up - 5-7 minute Low intensity free
categories in adult women and very little is known exercises
about exercise performance, well being and physical for 5-7 minutes.
functional capabilities in women.There exists a need to 2. Strengthening exercises- Strengthening exercise
assess physical functional status in adult women across with dumb bells and sand bag are given for upper
varying BMI categories. Till today studies are mostly limb and lower limb. 3 sets of 12 repetitions with
done in general population, but less research work done load of 60-70% of 1 RM.
as per varying BMI categories in women.
Upper limb: Overhead press, Biceps curl, Lateral
So the present study intended to find the influence pull
of therapeutic exercises on women with varying BMI on down, Triceps push-down, Bench press.
their physical functional status and quality of life.
Lower limb: Hip extension, Hip abduction,
Hamstring
Method curls, Calf raise, Squats.
The study was conducted at Physiotherapy 1. Stretching exercises- Stretching is given to
department of Krishna institute of medical sciences. various
Ethical permission was obtained from institutional muscles of upper and lower limb for duration
ethical committee, KIMS, Karad. 62 subjects were of
included and were divided into 4 groups according 30 seconds hold for each stretch with 3 repetitions
to their BMI. Subjects were selected according to Upper limb: Bicep stretch, Triceps stretch,
inclusion and exclusion criteria. Before including in the Trapezius
study they were asked to fill Physical Activity Readiness stretch.
questionnaire (PAR-Q). It consists of 7 questions which
they have to answer in YES or NO. If the answer is yes
90 Indian Journal of Public Health Research & Development,
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of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 90
Lower limb: Quadriceps stretch, Hamstring stretch, Hip
flexor stretch, Gluteus stretch, Hip adductor stretch, Calf
stretch.
1. Cool down: Low intensity free exercises to all the
joints for 5-10 minutes.
Primary assessment was done on Day 1 and post exercises assessment was taken at the end of 2nd Week and 4th
Week by Bench press, Leg press, YMCA-Step test, Sit and Reach test and SF-36.

Result

Outcome Measure
1. Strength test- 1-RM Test: Bench press and Leg press

Table1: Comparison of pre and post for strength within group

Pre Exercises 2Nd Week 4Th Week
Group Test Day 1 Post Exercises Post Exercises F Value P Value
Mean SD Mean SD Mean SD
Bench press 0.36 0.15 0.36 0.15 0.41 0.14 28.778 <0.0001
GROUP A
Leg press 1.12 0.16 1.14 0.17 1.17 0.17 26.692 <0.0001
Bench press 0.42 0.16 0.49 0.16 0.57 0.16 172.32 <0.0001
GROUP B
Leg press 1.10 0.22 1.17 0.21 1.27 0.22 152.05 <0.0001
Bench press 0.40 0.16 0.47 0.16 0.55 0.16 232.70 <0.0001
GROUP C
Leg press 1.02 0.20 1.11 0.21 1.19 0.22 86.414 <0.0001
Bench press 0.30 0.10 0.30 0.10 0.32 0.10 12.115 <0.0002
GROUP D
Leg press 0.76 0.19 0.77 0.20 0.77 0.20 12.283 <0.0001

The table shows the comparison of mean and standard deviation of pre and post values of 1-RM strength test
Bench press and Leg pressin Group A, B, C and D. The values are compared by applying Repeated Measures
ANOVA test followed by Tukey Kramer multiple comparison test. In all 4 Groups there was significant
improvement with p value <0.0001 respectively.
2. Endurance test: YMCA-Step test-

Table 2: Comparison of pre and post YMCA-Step test within group

Nd Th
Pre Exercises Day 1 Post Exercises 2 Week Post Exercises 4 Week
Group F Value P Value
Mean SD Mean SD Mean SD
Group A 112.00 8.05 111.20 6.44 110.73 8.25 1.448 0.2521
Group B 113.00 9.41 110.73 8.42 109.53 9.66 4.924 <0.0147
Group C 114.53 7.27 111.59 6.11 107.29 6.65 12.551 <0.0001
Group D 122.00 6.66 120.33 5.27 121.47 6.01 0.9288 0.4069

The table shows the comparison of mean and standard deviation of pre and post values of Group A, B, C and
D. The values are compared by applying Repeated Measures ANOVA test followed by Tukey Kramer multiple
comparison test. In Group B and C showed significant improvement with p value <0.0147 and <0.0001 respectively.
3. Flexibility test: Sit and Reach test-

Table 3: Comparison of pre and post Sit and Reach test within group
Nd Th
Pre Exercises Day 1 Post Exercises 2 Week Post Exercises 4 Week
Group F Value P Value
Mean SD Mean SD Mean SD
Group A 29.70 6.35 30.23 6.29 31.13 6.40 43.314 <0.0001
Group B 33.93 8.18 36.06 8.06 38.12 8.18 145.13 <0.0001
Group C 32.09 5.35 34.44 5.06 36.35 5.61 39.080 <0.0001
Group D 29.13 5.19 30.23 4.89 30.91 4.67 22.260 <0.0001
The table shows the comparison of mean and standard deviation of pre and post values of Group A, B, C and
D. The values are compared by applying Repeated Measures ANOVA test followed by Tukey Kramer multiple
comparison test. In all 4 Groups there was significant improvement with p value <0.0001 respectively.
4. SF-36 QOL

Table 4: Comparison of pre and post SF-36 within group

Pre Exercises Day 1 Post Exercises 2Nd Week Post Exercises 4Th Week
Group F Value P Value
Mean SD Mean SD Mean SD
Group A 34.52 7.48 35.95 7.45 39.52 7.57 58.500 <0.0001
Group B 53.57 5.05 57.62 5.54 62.62 5.21 134.67 <0.0001
Group C 51.89 6.45 56.93 5.85 63.45 5.72 98.372 <0.0001
Group D 36.19 6.60 40.24 6.54 45.24 7.95 57.863 <0.0001
The table shows the comparison of mean and for group A is 110.73(8.25), group B is 109.53(9.66),
standard deviation of pre and post values of Group group C is 107(6.65) and group D is 121.47(6.01) with
A, B, C and D. The values are compared by applying p value <0.0147 for group B and <0.0001 for group C.
Repeated Measures ANOVA test followed by Tukey
Kramer multiple comparison test. In all 4 Groups there Flexibility assessed by Sit and Reach Test shows
was significant improvement with p value <0.0001 post exercises (4th week) mean and standard deviation
respectively for group A is31.13 (6.40), group B is 38.12(8.18),
group C is 36.35(5.61) and group D is 30.91(4.67) with
Discussion p value
<0.0001.
The study was conducted considering all the
mentioned points and the aim of this study was to Quality was assessed by Sf-36 shows post exercises
evaluate the effect of exercises on physical functional (4th week) mean and standard deviation for group A
status of women according to their BMI categories. is 39.52(7.57), group B is 62.62(5.21), group C is
63.45(5.72) and group D is 45.24(7.95) with p
In this study 62 women were selected and were value
divided into 4 groups according to their BMI. All the <0.0001.
subjects were explained about aims and objective of the
study. Each group was given same strengthening and Overall in GROUP C all study variables shows early
stretching exercises. The pre and post exercises data was and significantly large change and also the same was
analyzed statistically using Repeated measures ANOVA observed in further follow up times.
(parametric methods) followed by Tukey Kramer
In this study an attempt was made to analyze the
multiple comparison test.
effect of strengthening and stretching exercises for upper
Strength of upper limb assessed by Bench Press and lower limb on strength, endurance, flexibility and
shows post exercises (4th week) mean and standard quality of life in women with varying BMI. Though it is
deviation for group A is 0.41(0.14), group B is known that aerobic exercises improves endurance but in
0.57(0.16), group C is 0.55(0.16) and group D is this study the subjects are given strengthening exercises
0.32(0.10); whereas for lower limb assessed by Leg and stretching for upper and lower limb to see its effect
Press post exercises(4th week) mean and standard on endurance.
deviation as for group A is
1.17(0.17) , group B is 1.27(0.22), group C is 1.19(0.22) Many literature states that muscle strength that can
improve and maintain the following9
and group D is 0.77(0.20) with p value <0.0001. post exercises (4th week) mean and standard
deviation
Step test used to assessed endurance (CRF)
shows
1. Bone mass that is related to osteoporosis.
2. Musculo-tendinous reliability that is associated to
a lower risk of injury including low back pain.
3. The aptitude to carry out the activities of daily 4. Definitions—Health, Fitness, and Physical
living, which is related to apparent quality of life Activity [Internet]. Washington (DC): President’s
and self-efficacy among other indicators of mental Council on Physical Fitness and Sports. 2000
health. [cited 2012 Jan 7]. 11 p. Available from: http://
4. The Fat Free Mass and resting metabolic rate, purl.access.gpo. gov/GPO/LPS21074
which are related to weight management. 5. WHO. Physical status: the use and interpretation
of anthropometry. Report of a WHO Expert
Resistance exercises have an effect on improving
Committee. WHO Technical Report Series 854.
strength 10 and bone density 11. Various studies shows
Geneva: World Health Organization, 1995.
benefit of resistance exercises is a significant component
for enrichment of health and progress quality of life 6. Source: Adapted from WHO, 1995, WHO,
even when the exercise is done in advance ages12-15. 2000
and WHO 2004.
The most vital criteria of health related Quality of
Life is body weight in women whereas very less data is 7. Garber CE, Blissmer B, Deschenes MR, et al.
available on women’s functional health status 16, so in American College of Sports Medicine Position
this study an effort is made to find the relation of the Stand. The quantity and quality of exercise for
women’s BMI and functional health. developing and maintaining cardio respiratory,
musculoskeletal, and neuromotor fitness in
apparently healthy adults: guidance for prescribing
Conclusion
exercise. Med Sci Sports Exerc. 2011;43(7):1334–
The present study concludes that the therapeutic 559
exercises has a significant improvement in women 8. ACSM’s guidelines for exercise testing and
pertaining to components of strength, flexibility and prescription / American College of Sports
quality of life, in all four groups; whereas only in group Medicine ; senior editor, Linda S. Pescatello ;
B and group C showed significant improvement in Step
associate editors, Ross Arena, Deborah Riebe,
Test (endurance). According to mean difference group
Paul D. Thompson. 9th ed. CHAPTER 4
C has shown more significant improvement then other
Health-Related Physical Fitness Testing and
three groups.
Interpretation. pg 105. www.acsm.org
Conflicts of Interest: There were no conflicts of interest 9. Williams MA, Haskell WL, Ades PA, et al.
in this study. Resistance exercise in individuals with and
Ethical Clearance: Ethical clearance was taken from without cardiovascular disease: 2007 update:
institutional committee of Krishna institute of medical a scientific statement from the American Heart
science, deemed to be University, Karad. Association Council on Clinical Cardiology and
Council on Nutrition, Physical Activity, and
Source of Funding: This study was funded by Krishna Metabolism. Circulation. 2007; 116 (5):572–84.
Institute of Medical sciences Deemed to Be University,
10. Fiatarone M, O’Neill E, Doyle Ryan N, Clements
Karad.
K, Solares G, Nelson M, Roberts S, Kehayias J,
Lipitz L and Evans W (1994): Exercise training
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DOI Number: 10.5958/0976-5506.2019.01543.2

Effect of Choice-Based Sensory Stimulation as a Coma

Stimulation Technique on Traumatic Brain Injury

Sayli D. Deshpande1, G. Varadharajulu2, Suraj Kanase3

1
Faculty of Physiotherapy, 2Dean, Faculty of Physiotherapy, 3Associate Professor, Krishna College of
Physiotherapy, KIMS ‘Deemed to be’ University, Karad, Maharashtra, India

ABSTRACT
Objectives: The purpose of this study was to check the effect of choice-based sensory stimulation as a
coma
stimulation technique on traumatic brain injury.
Method: 30 subjects diagnosed with traumatic brain injury were included in this study. These subjects
were divided into two groups using convenient sampling method with random allocation. The subjects
with Glass gow Coma Scale score 3-8 were included. Pre- treatment and post- treatment assessment for
both the groups was carried out by using WNSSP(WNSSP). This outcome measure was analyzed.
Result: The choice-based sensory stimulation showed the significance improvement in arousal
response
according to WNSSP. The P value was <0.0001, which is statistically
significant.
Conclusion: the present study provided evidence to support the use of choice-based sensory stimulation as
it is more effective than conventional coma arousal techniques in coma arousal on traumatic brain injury.

Keywords: Traumatic Brain Injury, choice- based sensory stimulation, Western Neuro Sensory
Stimulation
Profile
(WNSSP).
Introduction Traumatic brain injury secondary to road traffic
accidents mainly leads to coma.4-7
Traumatic Brain injury is defined as brain damage
caused by externally inflicted trauma to the head, Most of people are recovered frequently but suffer
may result in significant impairment of an significant with altered consciousness and cognitive function for
impairment of an individual’s functioning–physical, certain time period. If, these alterations persists for
cognitive & psychosocial.1 longer duration , then it will ultimately affect one’s
normal life.8,9
Traumatic Brain Injury is known to be a leading
Patients with coma are been hospitalized for longer
cause of morbidity, mortality, disability & socio-
duration and a complete bed rest which decreases the
economic losses in India.2
sensation perception due to reduced sensory stimulus.10
Traumatic brain injury causes long term effect on Coma is a state which endure for about months and
an individual’s life. About 5.3 million people in United years that will ultimately affect the quality of life of
States are living with disability due to brain injury.3 patient. There is an assumption that implementation of
well-planned
sensory stimulation program on severe TRAUMATIC
Correspondence Author: Phone: 8369294198
Sayli Dhananjay Deshpande MPT, Email: [email protected]
Faculty of Physiotherapy, Krishna
Institute of Medical Sciences Deemed
to be university,
Karad-415110, Maharashtra, India
BRAIN INJURY patient will have an
progressive effect on
arousal, recovery and sensory loss.10-13

Coma
Stimulation
Techniques

Various types of sensory stimulations

can be applied in patients with coma as a
coma arousal technique. They are as
follows:
95 Indian Journal of Public Health Research & Development,
Indian Journal July 2019,
of Public Health Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 95

1. Auditory: Allow one family member at a time to subject. This includes the interaction of the respective
interact with the subject. Use of radio, TV, tape family member with the subject. The family members
recordings of familiar voices, etc can also be had freedom for making their choice in accordance
useful. with the subject’s need for coma stimulation. The
2. Visual: For visual stimulation, subject must be above mentioned techniques are the choices which are
surrounded with brightly colored pictures, family available for the family members in concern with the
photo, any familier object and TV. Visual stimuli need of the subject. The family member was asked to
also include familiar faces (father, mother, tell their family stories, speak about the good and happy
brother, sister, husband, wife, friends etc.), moments which subject had spent with the family, show
familiar object, or a mirror. the family photo, apply the taste stimulus using cotton
swab(taste of subject’s favorite food ) etc. This stimulus
3. Tactile: Touch senses is either inhibiting or was given by the member who was closest to the
facilitating, e.g. pain, light touch are inhibiting subject. Due to emotional attachment between the
while light strokes to the back area result in subject and their family member, the impact of sensory
facilitating. Face is the most sensitive area. stimulation given by family member may help to gain
Variety of textures such as, clothing, blankets, better arousal response rather than stimulation given by
lotions etc. Squeezing technique of massage also the therapist.
can be applied. The pressure must be firm and
should not hurt the subject. Because of the visiting policies, there is lack of
interaction between the subject and family member. So,
4. Olfactory: In traumatic brain injury, olfactory
this study will be the effective measure to establish the
nerve is most commonly affected. Maximum
good interaction between subject and family member
subjects are intubated (i.e. tracheostomy, Ryle’s
which can be one of the most contributing factor for
tube etc.). For olfactory stimulus perfume, coffee
arousing the subject from coma
powder, shampoo, favourite food etc. can be used.
Olfactory senses should not be stimulated for Anyhow, little is known about the impact of family
more than 10 seconds as subject may get adapted involvement in providing sensory stimulation. This
to that. The stimuli should not touch the skin as study was beneficial, as the family member of the
subject can adapt and become less responsive to subject had the freedom for making their choice in
the stimuli. Irritable stimuli must be svoided such accordance with the subject’s need for coma stimulation
as vinegar, ammonia etc.
5. Gustatory: Subject must not be prone to the Method
aspiration. Cotton swab is dipped in sweet, salty
Population: Total 30 patients diagnosed with Traumatic
or sour solution and applied in the subject’s
Brain Injury by neurologist of KIMS hospital karad were
mouth. Sweet taste causes more salivation, so, in
selected as subjects. Subjects fulfilling the inclusion and
case of oral secretions, sweet taste must be
exclusion criteria were selected. Written consent was
avoided.
taken from family member of subject before starting
6. Movement: Range of motion exercises are used the study. Then subjects were divided in two groups i.e.
as movement stimulation Group A (experimental group) and Group B (control
7. Kinesthetic: Various changes in position such group) by convenient sampling method. Out of 30
as, rolling, rocking in chair etc. are used as subjects there were 21 male and 9 female.
kinaesthetic stimulation. Both male and female with GCS score below 8 and
subjects willing to participate in the study were
Choice-Based Coma Stimulation included. Whereas subjects with systemic illness;
GCS score 3 and auditory impairment were excluded.
Choice-based stimulation is applied directly by
the family member of the subject. It is an intervention Interventions: 30 subjects were divided into two groups
in which family members are directly involved for with 15 subjects in each group i.e. Group A
applying the coma stimulation technique to arouse (experimental group) and Group B (control group).
the Pre-treatment
assessment was taken according to WNSSP. Group A Movement Stimulus: Passive range of motion exercises
received a conventional sensory stimulation whereas were given to both upper limb and lower limbs. Ten
Group B received choice based sensory stimulation repetitions for each movement were given.
therapy (auditory stimulation, visual stimulation,
kinesthetic stimulation, movement stimulation, gustatory Group B (Control group) received conventional
stimulation). The list of the above mentioned techniques sensory stimulation:
was provided to the family member. And, then he/ z Group B i.e. control group received
she was asked to make their choice according to the auditory
subject’s need. After making the choice for stimulation, stimulus which was applied by therapist.
family members were asked to apply the stimulus under
the guidance of the therapist. Auditory Stimulus: This group too received auditory
stimulation. The audio was same for all the subjects in
Choice based stimulation was given to patient this group. An instrumental music was made to hear
using the information by family member (auditory, with the help of earphones. The duration of the audio
visual, movement and tactile) which was prepared by
was 10 minutes. These audio was made to hear for two
locally available and easily affordable material. Out
times a day for 5 days/week for 6 weeks.
of
15 relative of the subjects, 5 family members selected The treatment duration was same for both the
auditory stimulus, 7 family members selected visual
stimulus, 1 family member selected tactile stimulus, groups. Measurement procedure:
2 family members selected movement stimulus. The
treatment was given for 6 weeks; 5 sessions per week, WNSSP (WNSSP): For Pre-treatment and Post-
twice a day. Post treatment assessment was taken after treatment assessment was done by using WNSSP
completion of 6 weeks. (WNSSP). The WNSSP has thirty-three items
constituting nine cognitive- function subscales: Arousal
Group A (Experimental group) received choice- attention(4 items), Auditory response (2 items),
based sensory stimulation: Group A i.e. experimental Auditory comprehension (6 items), Expressive
group received auditory stimulus, visual stimulus,
communication (3 items), Visual tracking (7 items),
movement stimulus and tactile stimulus which was
Visual comprehension (5 items), Tactile response (2
totally applied by relative of patient.
items), Object manipulation (3 items), Olfactory
Auditory Stimulus: Auditory stimulus was given by the response (1 item). The total score range is 0 to 113; low
family member, the family member was asked to stand score indicates poorer function.14
nearby the subject. And he/she was asked to tell their
family stories (all the good and happy moments they had Result
spent with the patient). The time duration given to the
relative was 10 mins. They were asked to interact with Statistical analysis of pre and post intervention
patient throughout the time being given. Each patient within group was done by using non-parametric paired
received a different stimulus in form of different stories, test. Statistical analysis of pre and post intervention
different incidences, different voices etc. within group of non-parametric data (WNSSP) was
Visual Stimulus: Initially, the bed of the subject was done by Mann-Whitney test. The Choice-based sensory
elevated. Visual stimulus was given by placing the stimulation showed the significance improvement
family photo frame, familiar object, brightly colored in arousal response according to WNSSP with P =
pictures and mirror in front of the eyes of subject. The <0.0001, which is statistically significant. Among
subject’s eyes were opened passively by the family the
member. The time duration was same as above. 4 stimulus used for the choice-based stimulation i.e.
auditory, visual, tactile and movement stimulation;
Tactile Stimulus: For applying tactile stimulus, the visual stimulation showed considerable significance
subject was turned towards one side. Light strokes on with p=0.0156.
the back were applied. After that subject’s face was
moistened with help of wet cloth. Squeezing technique 1. Gender Distribution in the Study: Out of30
of massage was also applied on upper limbs. subjects 21 were males and 9 were females.
Group A had 11 males and 4 females and Group B
had 10 males and 5 females.
Table No. 1: Gender Distribution z Comparison of pre-interventional and post-
interventional scores for tactile and movement
GROUP A GROUP B TOTAL
stimulation.
MALES 11 10 21
FEMALES 4 5 9
Table No. 5: Comparison of pre and post WNSSP
TOTAL 15 15 30
for tactile and movement stimulation
Age Distribution in the Study: In this study,
Pre-Treatment Post-treatment
comparison of the age between group A and group B
was done. Mean and standard deviation of age for Mean 17.33 50.66
group A was 38.800± SD 2.887 6.028
13.143 while for group B it was 31.4000± 10.370. The Median 19.000 50.000
minimum age which was involved was 17.000 in group
A and 14.000 in group B. The maximum age which Discussion
involved was 60.000 in group A and 50.000 in group B
In this study, the main focus was on choice-based
2. Data Analysis WNSSP (WNSSP): sensory stimulation on traumatic brain injury subjects as
z Comparison of pre and post score of WNSSP a coma arousal technique.
within group A and group B.
It is an intervention in which family members are
Table No 2: Comparison of pre and post score of directly involved for applying the coma stimulation
WNSSP within group A and group B. technique to arouse the subject. This includes the
interaction of the respective family member with the
Pre test Post test P Value
subject.
Mean ± SD Mean ± SD
Group A 17.4 + 2.384 45.06 + 8.614 < 0.0001 The aim of the study was to identify better arousal
Group B 14.60 + 2.798 37.66 + 2.093 < 0.0001 response by seeing the effect of choice-based sensory
stimulation as a coma stimulation technique on
The analysis was carried out by Mann-Whitney test traumatic brain injury.
with extremely significant p value for both the groups as
< 0.0001 Out of 30 subjects, 15 subjects were conveniently
z Comparison of pre-interventional and post- included in group A i.e. experimental group and 15
subjects in group B i.e. control group. Pre-treatment
interventional scores for auditory stimulation.
assessment was taken according to WNSSP. Group A
Table No. 3: Comparison of pre and post WNSSP i.e. experimental group received choice-based sensory
for auditory stimulation stimulation which was applied by family members of
the subject while group B i.e. control group received
Pre-Treatment Post-treatment conventional sensory stimulation. Choice-based sensory
Mean 16.80 44.60 stimulation was in the form of auditory, visual, tactile
SD 3.03 5.85 and movement stimulation. The family member who
Median 18.000 48.000 was very close to the subject was involved in the study.
z Comparison of pre-interventional and post- The time duration for each stimulation given was 10
interventional scores for visual stimulation. minutes. This stimulus was applied twice a day for 5
days/week for 6 weeks. Conventional sensory
Table No. 4: Comparison of pre and post WNSSP stimulation was in the form of auditory stimulation.
for visual stimulation This was applied by the therapist. The stimulus was an
instrumental music which was made to hear to the
Pre-Treatment Post-treatment
subject with the help of earphones by the therapist. The
Mean 17.85 42.71 time duration was same for both the groups i.e. for 10
SD 1.952 10.73 minutes twice a day for 5 days/week for 6 weeks.
Median 17.000 45.000
The pre-treatment and post-treatment assessment REFERENCES
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DOI Number: 10.5958/0976-5506.2019.01544.4

Knowledge Attitude Practice on the Oral Hygiene Practices in

Children Below 12 Years

Shivani N1, Revathy Gounder2

1
Graduate Student, 2Assistant Professor, Department of Prosthodontics, Saveetha Dental College and
Hospital, Saveetha Institute of Medical and Technical science, Saveetha University, Chennai, India

ABSTRACT
The brushing techniques in children are different when compared with those in adults. Children of this age
category are more prone to tooth decays. When the primary teeth has decays and is not treated, it may infect
the primary teeth and hence this research is important to prevent infection. Two hundred participants aged
between 3-12 were recruited through a survey. A questionnaire was administered to generate information
on oral hygiene practices. This was an online survey undertaken by using the link https://surveyplanet.
com//.Oral hygiene is of major concern and only 43.4% people take proper care. It is also seen that about
72% children use toothbrush to brush their teeth. It is also seen that majority of the children, about 72% use
toothpaste. Whereas about 4% people use salt and water or oil for brushing. The level of individuals
utilizing oral cleanliness helps other than toothbrush and toothpaste was less. Subsequently, the dental
experts need to instruct and inspire individuals about the oral cleanliness support alongside legitimate
choice and utilization of the different oral cleanliness helps.

Keywords: Oral cavity, Plaque, Hygiene, Cleanliness, Brushing techniques.

Introduction Individual’s oral health-related behaviours and
their outcomes are influenced by individual, family and
Oral hygiene is a practice to maintain one’s mouth
the community.[2] Over the last century, oral health has
clean and disease free by brushing and cleaning. Oral
improved significantly. This improvement, however,
hygiene should be maintained in children as they’re
has not been experienced equally across the population,
more prone to carries and an infection in primary teeth
being considerably greater among the better off.[3] High
may cause infection in permanent ones.[1] Oral hygiene
economic status alone cannot contribute to better health.
is the an effective medium to prevent caries and [4]
Although it is a major factor for improving the health
periodontal diseases. Ideally, brushing should be [4,5,6,7]
it can be a contributing factor for illness as well,
performed twice a day in order to maintain oral health.
like in the occurrence of coronary heart disease,
An important family level factor is the socio-economic
diabetes, and obesity.
status. Important community level factors are those
associated with ease of access to health care.[16] The purpose of oral hygiene is to prevent the buildup
of plaque, the sticky film of bacteria and food that forms
on the teeth. Plaque sticks to the fissures and crevices of
the teeth and generates acids which, when not removed
Corresponding Author:
on a regular basis, slowly decay, the enamel surface of
Dr Revathy Gounder, M.D.S.,
the teeth, causing cavities. Plaque also irritates gums and
Assistant Professor, Department of Prosthodontics
can lead to gum disease, periodontal disease, and tooth
Saveetha Dental College,
loss.[8]
Saveetha Institute of Medical and Technical Sciences,
Saveetha University, 162 Poonamallee High Road Oral hygiene can be maintained by brushing and
Chennai-600077, Tamil Nadu, India flossing. Regular brushing consists of brushing twice a
Mobile: 8682873804 day: after breakfast and before going to bed. Cleaning
Email: [email protected] between the teeth is called interdental cleaning and is as
important as tooth brushing.[9]
101 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 101

The primary risks arise from a lack of proper oral area. The oral hygiene habits of the study population
hygiene practices. These major oral health problems are were assessed including the use of oral hygiene aid,
plaque, tartar, gingivitis, periodontitis, and tooth decay.[10] frequency of cleaning teeth, duration of cleaning teeth,
frequency of changing toothbrush, rinsing of mouth with
Excessive body weight in children is a major public
water, use of mouthwash, and tongue cleaning aid used.
health problem. One of the main reason for obesity is
intake of excess sugar. Sugar containing snacks and soft Inclusion Criteria:
drinks, is reported to be more common among
z Systemically healthy individuals aged between
overweight and obese children/adolescents than those
3-12 years.
with normal weight. Frequent sugar intake is also a
recognized risk factor for dental caries. Sugar acts (and z The patients willing to give informed consent were
other fermentable carbohydrates such as highly refined included in the study.
flour) as a risk factor in the initiation and progression of z Patients with history of systemic disease
dental caries. Sugar acts as a favoured substrate for the (debilitating disease or any condition having a
cariogenic bacteria that reside in dental plaque, substantial effect on oral health)
particularly the mutans streptococci, and the acid by-
products of this metabolic process induce z Pregnancy and lactation
demineralization of the enamel surface. Thus, the aim of z Undergone oral prophylaxis during the past 6
the survey is to create awareness on the oral hygiene months.
practices among children below 12 years.
Ethical Clearance: Informed consent was obtained
from the patients who participated in the study.
Materials and Method
Statistical analysis: Collected data was entered into
A cross-sectional survey was done to assess the oral
Microsoft Excel and analyzed using Statistical Package
hygiene habits. The questionnaire included the questions
for Social Sciences version 21.0 software (IBM Inc.,
related to the demographic profile and assessment of the
Chicago, USA). Descriptive statistics (number and
oral hygiene habits of the study population.
percentage of responses for the questions related to
The questionnaire included information related to the oral hygiene practices including the demographic
the information) were calculated for response items.
patient’s name, age, gender, occupation, and residential

Table 1: The oral hygiene of children below 12 years has been analysed through questionnaires
Questions Responses Number Percentage
Once in a day 110 54.4
How many times do you
Twice in a day 80 38.8
brush in a day?
Never 16 7.8
Everyday 80 38.8
How often do you floss? Rarely 90 43.7
Never 36 17.5
Once in a year 73 44.2
How often do you consult
During pain 91 20.4
the dentist?
Once in 6 months 42
1 minute 44 21.4
For how long do you
2minutes 120 58.3
brush?
Less than a minute 42 20.48
Everyday 90 43.7
How often do you
Sometimes 82 39.8
consume chocolates?
Rarely 34 16.5
Conted…
Everyday 64 31.1
How often do you face the
Sometimes 88 42.7
problem of bad breath?
Rarely 54 26.2
Do you have any tooth Yes 70 34
caries? No 136 66

Fig. 1. Graph showing number of times brushing a Fig. 4. Graph showing toothbrush usage percentage
day

Results

Oral hygiene is of utmost importance. In the present

study, the oral hygiene of children below 12 years has
been analysed (Table 1). Oral hygiene is of major
concern and only 43.4% people take proper care. It is
also seen that about 72% children use toothbrush to
brush their teeth (Fig.1). It is also seen that majority of
the children, about 72%, use fluoride containing
toothpaste. Whereas about 4% people use salt and water
or oil for brushing (Fig.2). The brushing techniques
Fig. 2. Graph showing gargle after eating used more commonly is the bass method technique
(34.5%), the second most common technique is the
horizontal brush technique (29.6%) (Fig.3).

Discussion
This study is done to grow awareness about the
healthy practices of oral hygiene. Children who had
good knowledge of caries prevention measures had
significant increased odds of brushing their teeth twice
daily or more.[11- 15]
The toothbrush and toothpaste utilize is the best
Fig. 3. Graph showing brushing techniques method for cleaning the teeth and keeping up the oral
cleanliness. To amplify the oral wellbeing, the American
Dental Association and US Surgeon General suggest The SES affects the oral cleanliness practices of
that people brush twice and floss in any event once the patients as it influences the moderateness of the
every day and have customary prophylactic dental visits. populace. The advancement and usage of very much
organized dental wellbeing training programs on
Rinsing of mouth with plain water was accounted by
occasional premise are expected to enhance and keep
54% of the kids in the present investigation with larger
up appropriate oral wellbeing measures among civil
part washing their mouth after suppers (55%) (Fig.4).
representatives with uncommon accentuation on the
This was vastly improved than the investigation of Jain
et al. [17] just 29% of the example populace washed their lower SES strata.
mouth subsequent to eating sustenance. This essential Source of Funding: Nil
propensity for oral cleanliness was observed to be very
among this investigation populace. Conflict of Interest: Nil

Money related contemplations, instructive status,

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DOI Number: 10.5958/0976-5506.2019.01545.6

Role of Tumour Necrosis Factor Alpha (TNF-α) in Pulmonary

Pathophsiology of Chronic Obstructive Pulmonary Disease

Smriti Gupta1, Ajit Kumar2, Vishwajeet Rohil3, Anuj K. Bhatnagar4

Research Scholar, Department of Chemistry & Biochemistry, SRM University, Delhi-NCR-Haryana, &
1

Department of Clinical Biochemistry VP Chest Institute, University of Delhi, Delhi; 2Associate Professor,
Department of Chemistry & Biochemistry, SRM University, Delhi-NCR- Haryana; 3Assistant Professor,
Department of Clinical Biochemistry, VP Chest Institute, University of Delhi, Delhi; 4Consultant Chest
Specialist & HOD (Chest&TB), Rajan Babu Institute for Pulmonary Medicine & Tuberculosis, Delhi,
India

ABSTRACT
Tumour Necrosis Factor (TNF-α) is one of the most commonly studied cytokine of TNF superfamily.
Patho-physiologically generation of high levels of TNF-α is a development of inflammatory responses for
many of the chronic diseases. Simultaneously in pulmonary diseases increased level of TNF-α in blood
serum relates with the cytotoxicity. The Study was conducted on 100 patients of Rajan Babu Institute for
Pulmonary Medicine & Tuberculosis (RJPIMT) Hospital. Patient diagnosis was confirmed via Spirometry.
The result reveals that the serum TNF-α level increases with the COPD severity. The mean values of TNF
were significantly increased with the decreased FEV/FVC. The present study showed that serum TNF-α
level correlates with severity of airway obstruction in Spirometry among the COPD patients. It is worth
mentioning that serum TNF-α level may plays an important role to diagnose chronic obstructive pulmonary
disease as a useful marker to monitor the disease severity in addition to spirometric parameters like FVC,
FEV1 and FEV1/FVC ratio.

Keywords: TNF-α, COPD, Exacerbations,

Spirometry.

Introduction of inflammatory cytokines. (7). Around 30 million people

in India are suffering from COPD (8) and almost half a
Chronic Obstructive Pulmonary Disease (COPD) is
million people die in India every year due to COPD.
one of the crucial hazardous diseases with an increase in (9) One of the study conducted by WHO estimated that
morbidity and mortality rate of life all across the world. COPD was the fifth leading cause worldwide in 2001
It is among one of the disease-causing large amounts of with 250 million patients mortality and it is to be the
economic burden over the globe. As reported by WHO, leading cause by 2020. (10) Abe-Gunde et al. in his study
COPD will be the fourth largest leading cause of death revealed that out of a total number of deaths taken place
by 2020.(1,2,3) in 2005, 7% of these were caused by chronic respiratory
diseases and 80% of it occurred in under-developed
COPD is defined as characterized persistent airflow
and developing countries. (11) The world-wide studies
progressive limitation and associated with inflammatory
conducted showcased that incidences of COPD in stage
responses in the airway to noxious particles or gases.
II or severe cases were 10.1% including 11.8% for men
Another variable of exacerbation and comorbidities
and 8.5% for women. (12) In one of the report of
contributes towards the severity of diseases.(4)
Economic Fabric of India (2001) it was stated that in
Pathologically COPD consists of two major conditions
total of 14.93 million cases of COPD; 5.02 million cases
of Emphysema; shortness of breath (5) and Chronic
were females and 9.92 million males.
Bronchitis; production of a chronic cough and sputum for
at least three months a year for two consecutive years.(6) The systematic inflammatory process in the
lungs activates the peripheral inflammatory cells by
COPD is also associated with systematic
releasing several cytokines and chemokines. (3) TNF-α
oxidative
is responsible for cellular migration and activates the
stress, circulatory inflammatory cells and increase level
106 Indian Journal of Public Health Research
Indian & Development,
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 106

secretion of various cytokines. (13) TNF-α is known as a other co-morbidity like cardiovascular, diabetic or
factor produced by endotoxin-stimulated macrophages any
causing necrosis of a tumour. (14) Among various studies other disease are excluded from the study.
conducted all across the world increased serum TNF- α
levels were seen from the sample of COPD patients. Spirometry: For diagnosis of COPD, spirometry test
is performed. The spirometry test is a technique and a
(15,16,17)
The overproduction of TNF-α results into
qualitative analysis of post-bronchodilator FEV/FVC.
pulmonary emphysema and inflammation (18,19,20) and
the counter effects are displayed as stimulation of release Serum TNF-α Estimation: Serum TNF-α level assay
of enzymes like macrophage metalloelastase. (21) A was conducted using Ray-Bio Human TNF-α Kit. It is
meta-analysis study revealed positive association between an in vitro enzyme-linked immunosorbent assay for the
COPD and inflammatory systemic markers. (22). In this quantitative estimation of human TNF-α in serum. This
study, we have made an attempt to measure the TNF – α assay employs an antibody specific for human TNF-α
level in patients with COPD and to correlate with the which is coated on a well plate.
severity of disease with special reference to Delhi-NCR
Samples and standards were pipetted into the well
population.
plate. TNF-α present in the sample binds to the well
by immobilized Ab in the incubation period. Wells
Methodology were then washed and human TNF-α antibody was
added. After washing the unbound antibody the HRP-
For concise study, detection of the severity of Conjugated Streptavidin was added to the well and
disease complete and comprehensive medical history colour was developed in amount of the TNF-α bounded.
is required. Patient’s detailed information are collected Stop solution was added to stop the reaction which
through structured and validated questionnaire.(23) changed the colour from yellow to blue and then plate
was read in ELISA reader at the 450 nm.
The study was carried out on patients attending the
pulmonary medicine department of (RJPIMT) Hospital, Statistical Analysis: Data are expressed as mean ±S.D.
New Delhi. The patients from various age groups were The comparison of variables between smokers and non-
included in the study which was conducted on 100 smokers COPD and smoker and non-smoker control
were performed using students t-Test. As per value
patients suffering from COPD with or without smoking
below 0.05 was considered statistically significant.
as a prime factor. The patient Blood samples were
The Pearson’s correlation was used to evaluate the
collected only after informed consent from each subject relationship between variables.
included in the study. All inclusion and exclusion
criteria were fulfilled.
Results
Inclusion Criteria: All patients who are diagnosed
The TNF-α serum levels were significantly higher
with COPD after spirometry confirmation as defined by
in the smoker group of COPD patients compared to the
the GOLD guidelines are included. Various symptoms
non smoker group of COPD patients (P<0.05). It was
are also added on as a key indicator helping in better
also identified that a strong negative correlation was
accessibility of disease.
seen between FVC/FEV and TNF-α for smoker group
Exclusion Criteria: Patients, with Sputum positive whereas weak correlation was seen between FEV/FVC
pulmonary tuberculosis, asthma patients and patients and TNF- α in non-smoker group of COPD patients. The
with bronchiectasis, acute exacerbation or with any variables of the four study group are shown in Table 1.

Table 1: The characteristics of Smokers and Non-Smoker group

COPD Non–COPD
Variables
Smoker Non Smoker Smoker Non Smoker
Age 54.25 (10.47) 54.86 (10.01) 50.669 (9.71) 50.39 (9.47)
Male 100% 78.30% 100% 78%
Female NA 21.60% NA, 22%
Pack years 30.16 NA 12.18 NA
FEV/FVC 47%, 52% 83% 85%
The average age is not statistically significant Figure 1.The serum level of TNF-α between diseased
between the smoker and non-smoker group of control smoker and control smoker group were statistically
and diseased patients. The result reveals that the serum significant (p< 0.005) as shown in Figure 2.
level of TNF-α was significantly elevated in smoker
group of COPD and control patients shown in Figure 1. Discussion
The serum level of TNF-α between diseased smoker and
control smoker group was statistically significant (p< COPD as the disease has taken a challenging role in
0.005) as shown in Figure 2. the medical industry. Total sample population collected
were 220, male 206 (93.6%) and female 14 (6.8%).
It is because of the smoking as one of the prime risk
factors for COPD. 6.8% were females with a history of
exposure to smoke either from cooking through biomass
fuel or using Hay Stick.

Chapman et al. studied occurrence of COPD

and showed increase rate of the disease in males than
females. (24) Mahesh et al. based on his validated
structured questionnaire for COPD in rural area of
Mysore concluded the prevalence of disease to be more
common in males (11.1%) in comparison to females
Figure 1: Depicting negative correlation (4.5%).(25) Bednarek et al. in his study revealed about the
of diagnosis of COPD and concluded that degree of post-
COPD smokers with TNF-α and FEV/FVC bronchodilator airflow limitation was mild in 30.6%,
(%) moderate in 51.4%, severe in 15.3% and very severe in
2.7%. (26) Mathanraj et al. in his studies concluded that
majority of the COPD cases were found to have
moderate (44.4%) and severe (39.8%) airflow
obstruction. (27)

It can be easily related that increasing awareness on

health issues in western countries has more emphasizing
effect on early diagnosis and detection of disease
whereas in developing nations like India due to lack of
awareness and overpopulation diseases are generally
detected at the tertiary care stage.

Figure 2: Histogram representing significant Vigg A et al. studied the prevalence of COPD in a
correlation of TNF-α between smoker COPD and tertiary care hospital in southern India and concluded
smoker control that among 946 patients studied 30% has mild and
The high levels of TNF-α in the serum of smokers moderate disease and whereas 40% has severe COPD.
and strong negative relation correlation between
(28)
Haehling V.et al. (29) revealed that serum TNF-α was
efficiency of lung FEV/FVC were found. The TNF- α found significantly higher in COPD patients compared
level value in serum indicates an imbalance between to controls.
pro-inflammatory and anti-inflammatory factor due to
This confirms previous studies similar to our
smoke exposure. The study concludes by showing that
proposed study i.e. the levels of TNF-α increases with
serum TNF-α is directly proportional to the disease
the disease severity. In our study, we were also able to
severity and indirectly proportional to the FEV/FVC
correlate that smoking was somehow associated with
(airway obstruction ratio) of the patients.
higher TNF-α -mediated systematic inflammation in
The serum level of TNF-α were significantly COPD patients.
elevated
in smoker group of COPD and control patients shown in
The main purpose of this study was to measure the Conflict of Interest: The authors declare that there are
TNF-α level in Delhi-NCR subjects and it implication no Conflicts of Interest.
as a biomarker for the early detection and diagnosis of
COPD. To the best of our knowledge, this is the first Source of Funding: Self
study conducted in Delhi-NCR Population which
Ethical Clearance: The study was conducted after the
showcases a clear strong correlation between decreased
ethical clearance from the review board of Hospital
FEV/FVC and elevated serum TNF α level which
(S.No 0591/RBIPMT/2016).
indicates the activation of inflammatory responses in
COPD. It also shows that levels of TNF-α can be used
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DOI Number: 10.5958/0976-5506.2019.01546.8

Effect of Closed Kinematic Chain Exercises on Distal Muscle

Weakness in Post Guillain Barre Syndrome

Sneha G. Narlawar1, G. Varadharajulu2, Suraj Kanase3

1
Faculty of Physiotherapy, 2Dean, Faculty of Physiotherapy, 3Associate Professor, Krishna College of
Physiotherapy, KIMS ‘Deemed to be’ University, Karad, Maharashtra, India

ABSTRACT
Objectives: The purpose of this study was to check the effect of closed kinematic chain exercises on distal
muscle weakness in post Guillain Barre Syndrome.
Method: 30 subjects diagnosed with post guillain baree syndrome were included in this study. These
subjects were allocated by convenient sampling method. The subjects with manual muscle testing grade 3
and above were included. During Pre treatment and post treatment assessment upper limb muscle strength
was measured by handheld dynamometer and for lower limb passive dorsiflexion range was measured by
goniometer. These outcome measures were analyzed.
Result: Pre and post treatment protocol was analyzed by using paired t test. Data analysis showed
extremely
significance for handheld dynamometer (p=0.0001) and goniometer (p=0.0001).
Conclusion: The effect of closed kinematic chain exercises for distal muscle weakness has shown
good
progress in post Guillain barre syndrome subjects with the help of handheld dynamometer and Goniometer.

Keywords: closed kinematic chain exercises, distal muscle weakness, Guillain Barre
Syndrome.
Introduction GB syndrome occurs at any age. It usually follows
viral infection, rarely after surgery or immunization.
Guillain-Barré syndrome (GBS) is defined as an
The most common identified precipitant of GBS is
acute, inflammatory, post-infectious autoimmune
Campylobacterial infection.8Symmetrical weakness
polyneuropathy which leads to demyelination of the
of muscle present in this syndrome along with some
peripheral and autonomic nerves which results in acute
wasting, hypotonia and partial or complete loss of deep
sensory and motor losses.1, 2 It is also known as acute
tendon reflexes.9
inflammatory demyelinating polyradiculoneuropathy.
Symmetrical motor paralysis occurs due to the Motor symptoms start distally and move proximally,
demyelination of peripheral nerve axons, which gradually first there is involvement of lower limb than upper limb
progress and ascends from the lower extremities and then progressively it involves trunk and cranial muscles.
leads to tingling, burning sensations and areflexia.3,4,5 Variable symptom is pain, tenderness occurs on deep
Altered soft-tissue length, muscle weakness, and sensory pressure especially to motor points in muscle and nerve
changes that affect the balance, posture, joint mobility and trunk and also parasthesia.9, 10
gait.1,2,6,7
Annual incidence is 3.0 cases/100,000 populations
throughout the world. Men are about 1.5 times more
Corresponding Author: Sneha
likely to be affected than are Women. And children < 1
Gopalkrishna Narlawar, MPT,
year of age are affected very rare.11
Faculty of Physiotherapy,
Krishna Institute of Medical Sciences Pathophysiology: GBS has complex pathophysiology.
Deemed to be university, Immune system begins to attack the body itself, due
Karad-415110, Maharashtra, India to involvement autoimmune responses. Cross reaction
Phone: 7385513119 is caused between immune responses and the neural
Email: [email protected]
112 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 112
112 112
tissue. This disease affects the spinal roots and nerve, muscles of extremity in order to improve quality of daily
primarily the involve the Schwann cell. Initially this living activities. Weight bearing position is an important
results in segmental demyelization of the nerve process element in distal muscle recovery. The effect of Closed-
and later proliferation of the Schwann cell. The axon kinematic chain exercises on distal muscle weakness in
remains intact and conduct an impulse with reduced post GBS have been elaborate in detail.
velocity, later axonal degeneration may occur in some
subjects which cause complete conduction block.9 The Method
peripheral nervous system is associated with
perivascular lymphocytic inflammatory exudates. Population: The subjects which willing to participate
Recovery occurs by axonal regeneration and in the study was taken. The criteria for inclusion were:
remylienation of peripheral axons. Internodal distance clinically diagnosed with recovery stage of GBS and
is less because of mylien sheet is thinner and there is MMT grade 3 and above. Subjects were excluded if they
increase in number of nodes of Ranvier. Nerve had any recent fracture, any recent surgery, any
conduction velocity is within the normal limits in less cardiopulmonary disorder and acute progressive stage of
GBS.
severe cases. However conduction velocity may be
permanently abnormal, where axonal damage are 30 post Guillain Barre Syndrome survivors were
occur.9,10 selected from outpatient department of physiotherapy.
Out of 30 subjects 20 males/10 females participated
Closed kinematic chain of movement: In a moving
in this study, written consent form was taken. All the
segment if one end of the joint is fixed(either proximal
subjects were informed about the protocol and gave
or distal),movement of one joint if it accompanies the
written consent before their participation. The protocol
movements are another joint involved with the segment
and the consent form were previously approved by
is called as closed kinematic chain movement.
protocol and ethical committee.
The exercises framed on this basis are called as
Interventions: Subjects who were referred to
closed kinematic chain exercises.
physiotherapy department and they were diagnosed
Examples; squatting, prone pushups, press up or by Physiotherapist of Krishna Hospital, Karad, as
pull up, lunges recovery stage of guillain barre syndrome were selected.
Further they were screened clinically and diagnosis was
Neurophysiology: Closed kinematic chain exercises confirmed. Considering inclusion and exclusion criteria
stimulate the proprioceptive system by proprioceptive they were requested to participate in the study. The
feedback to initiate and control muscle activation nature of study and intervention were explained to the
pattern.12,15,16During the early phase of training, subjects and those who were willing to participate were
conscious awareness of joint position or movement included. Before proceeding to intervention a written
is one of the important factor of motor learning for consent was taken from subject. A brief demographic
neuromuscular control. Closed chain exercises provides data was recorded. By using convenient sampling
greater proprioceptive and kinesthetic feedback than method the participants was included; the subjects with
open chain exercises.13 Because multiple muscle groups manual muscle testing grade 3 and above were included.
are activated which cross multiple joints during CKC . During Pre treatment and post treatment assessment
Therefore , more sensory receptors are activated which upper limb muscle strength was measured by handheld
present in muscle ,intra-articular and extra-articular dynamometer and for lower limb passive dorsiflexion
structures to control motion .The axial loading of CKC range was measured by goniometer. The treatment was
causes joint approximation to stimulate given for 6 weeks; 5 sessions per week.
mechanoreceptor in muscles and in and around joints
Protocol was consisting of following exercises
which enhance sensory input for movement control . It for
also facilitate coactivation of agonist and antagonist upper limb and lower limb respectively;
that is co-contraction of muscle occurs.14
For Upper limb:
Distal muscle weakness is major problem in post
GBS individuals. There is delayed recovery in distal Prone pushups: Subject was in prone lying position.
muscle weakness; so, we need to strengthen distal Then taking weight on both hands and toes .He/she had
to lift the whole body and go down.
Wall pushups: The procedure of wall pushups was same Measurement Procedure:
as prone pushups, but instead of lying in prone position
he/she had to stand opposite to the wall. Handheld dynamometer: Subject were in seated
position with the shoulder Adducted and neutrally
Quadruped: The subject position with weight bearing rotated, the elbow was flexed at 90º, and the forearm and
on both hands with extension of both the elbows and on wrist remain in neutral position17,18 and ask subject to
both the knees with hip and knee 90 degree flexion and squeeze the hand grip of hand held dynamometer with
ankle plantar flexed. Maintaining this position the maximum efforts which is maintained for 5 sec.
perturbation was given. Along with perturbation, and after that the value is recorded. Three reading were
subjects had to tuck in the abdomen and curve and taken and average final value is recorded.
19

flatten the back alternately to facilitate pelvic tilts that is

Goniometer: Testing position: subject was in supine
cat and camel exercises.
position with knee flexed at 90 degree.
Sitting press ups(pull up): Subject was sitting on firm
Goniometer alignment: The fulcrum of goniometer
surface. Then place his/her hands on both the sides was placed over the lateral malloeolus. The stationary
respectively. Now ask the subject to press both the hands arm was aligned up along the fibula and movable arm
against the firm surface and lift up the pelvis off from the with parallel to the fifth metatarsal bone.
firm surface.
Testing motion: The subject was asked to dorsiflex their
For Lower limb: ankle with the therapist’s assistance.

Squatting: Subject must stand opposite to wall with

Result
back resting on wall. He/she had to do mini squatting
by flexing both the hip and knee at minimum ranges and Pre and post treatment protocol was analyzed by
then getting up back to standing. using paired t test. Data analysis showed extremely
significance for handheld dynamometer (p = 0.0001)
Lunges: Subject was to stand with one leg in front of
and goniometer (p = 0.0001).
another leg and then had to go down with flexing the
front leg and do the vice versa for another leg. Statistical analysis: The data was entered into
Microsoft office excels 2007 and analyzed using instat
Step up and step down exercises: Subject was stand software. Descriptive statistics were used to analyze for
with weight bearing of the both the legs. Then asked to demographic data : Pre and post treatment protocol was
he/she to step one leg forward (i.e. step up) and take it analyzed by using paired t test and p value <0.0001 was
back (i.e. step down), then vice versa for another leg. considered to be statistically significant.

Leg press: Subject while sitting on the therapeutic As per the inclusion criteria 30 subjects were
gymnasium sled had to extend the knee while pushing included in the study. During 6 weeks of protocol
the footboard forwards. program closed kinematic chain exercises was given for
both upper limb and lower limb. Pre and post analysis
After 6 weeks Post treatment assessment values was was done for 30 subjects. In Table.1 to Table.4
taken. Then by statistical analysis result was calculated.

Table 1: Comparison of mean and SD pre and post treatment of Handheld dynamometer for right upper limb
Pre treatment HHD Post treatment HHD
Sr. No. Parameters P value Significance
Mean SD Mean SD
1. HHD 3.53 1.252 5.53 2.446 <0.0001 Significant

The values were compared by applying wilcoxon matched pairs test. Pre and post treatment values shows that
there is extremely significant difference in HHD for right upper limb (<0.0001).
Table 2: Comparison of mean and SD pre and post treatment of Handheld dynamometer for left upper limb
Pre treatment HHD Post treatment HHD
Sr. No. Parameters P value Significance
Mean SD Mean SD
1 HHD 3.36 1.37 5.36 2.50 <0.0001 Significant

The values were compared by applying wilcoxon matched pairs test. Pre and post treatment values shows that
there is extremely significant difference in HHD for left upper limb (<0.0001).

Table 3: Comparison of mean and SD pre and post treatment of goniometer for right lower limb

Sr. Pre treatment Goniometer Post treatment Goniometer

Parameters P value Significance
No. Mean SD Mean SD
1 Goniometer 3.13 1.306 7.93 2.463 <0.0001 Significant

The values were compared by applying wilcoxon matched pairs test.pre and post treatment values shows that
there is extremely significant difference in Goniometer for right lower limb(<0.0001)

Table 4: Comparison of mean and SD pre and post treatment of goniometer for left lower limb

Sr. Pre treatment Goniometer Post treatment Goniometer

Parameters P value Significance
No. Mean SD Mean SD
1 Goniometer 3.0 1.21 7.66 2.35 <0.0001 Significant

The values were compared by applying wilcoxon matched pairs test.pre and post treatment values shows that
there is extremely significant difference in Goniometer for left lower limb(<0.0001).
Discussion measurement taken by handheld dynamometer for upper
limb and goniometer for lower limb.
In GBS there is delayed recovery happened at the
distal part of extremity. So, the recovery of these Wilcoxon matched-pairs t test used to analyze the
muscles is important factor on day today activities. In effect of CKC exercises on distal muscle weakness on
these studies we focus on closed kinematic chain hand-held dynamometer shows extremely significant
exercise as a key treatment strategy. improvement in right upper limb strength with p value
of 0.0001. Pre interventional value of mean and standard
The aim of studies was to find the effect of closed
deviation was 3.53 ± 1.252 and post interventional
kinematic chain exercises on distal muscle weakness
value of mean and standard deviation was 5.53 ± 2.446
in post Guillain Barre Syndrome subjects. According
and also shows extremely significant improvement in
to hypothesis the significant improvement in outcome
left upper limb strength that is p value of 0.0001. Pre
measures observed after the treatment of closed
interventional value of mean and standard deviation was
kinematic chain exercise.
3.36 ± 1.37 and post interventional value of mean
Subjects were included according to inclusion and
criteria. Both males and females were included. Out standard deviation was 5.36 ± 2.50.
of
Wilcoxon matched-pairs t test used to analyze the
30 subjects, 20 were males and 10 were females.
effect of CKC exercises on distal muscle weakness on
The
goniometer shows extremely significant improvement
closed kinematic chain exercises was given for 6 weeks;
in right lower limb range of motion with p value
5 sessions per week. Post treatment assessment was
of
taken after completion of 6 weeks.
0.0001. Pre interventional value of mean and standard
There was significant improvement in distal muscle deviation was 3.13 ± 1.306 and post interventional value
strength after the entire treatment programmed. The of mean and standard deviation was 7.93 ± 2.463
and
also shows extremely significant improvement in left 2. Garssen MP, Bussmann JB, Schmitz PI, et al.
lower limb range of motion with p value of 0.0001. Pre Physical training and fatigue, fitness, and quality
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individuals. The above findings is due to the pattern of
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Conflicts of Interest: There were no conflicts of interest clinical problems ;Fourth Edition ;Darcy Umphred
in this study. , Neuromuscular Diseases ; pg no.386
12. Lo YL. Clinical and immunological spectrum
Source of Funding: This study was funded by Krishna of
Institute of Medical sciences Deemed to Be University, the Miller Fisher syndrome. Muscle Nerve.
Karad. Nov
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DOI Number: 10.5958/0976-5506.2019.01547.X

Rugoscopy: An Adjunctive Diagnostic Tool for Malocclusion?

Swapna B V1, Sheetal Shetty2, Smitha S Shetty3

Associate Professor, Department of Prosthodontics, 2Assistant Professor, Department of
1

Conservative Dentistry and Endodontics, 3Associate Professor, Department of Oral Pathology,

Faculty of Dentistry, Melaka Manipal Medical College, Manipal, Karnataka

ABSTRACT
Context: Palatal rugae (PR) are regularly used in forensic dentistry for identification of individuals. PR
gets established early in intra-uterine life and remains stable thereafter, thus considered as a stable land
mark. Correlation of PR with different occlusal relations may aid in diagnosing malocclusions at an early
stage.
Aims: Identification of distinctive features of PR in different classes of dental malocclusion and to identify
the most common pattern in Malaysian students. To explore probability of PR as an adjunctive tool for
categorizing malocclusions.
Method and Material: PR in casts of 70 Malaysian students aged 19-23 years demonstrating Class I, Class
II and Class III malocclusions were studied. The number, pattern, orientation and strength of rugae both on
left and right side of mid-palatal raphe were determined and statistically analysed by anova test for
different categories of malocclusions.
Results: Class I malocclusion showed similar bilateral orientation of all the parameters when compared to
other two types of malocclusion. PR in all malocclusions showed a predominantly wavy pattern but
forking- diverging type was mainly in fragmentary rugae. The number of primary, secondary and
fragmentary rugae was greatest in number in Class II malocclusion when compared to class I and class III.
Conclusions: This study provides evidence of a distinct pattern of PR in Class I and Class III patients and
but to ascertain its statistical significance, further research may be conducted with a larger sample size.

Keywords: malocclusion, palate,hard ,diagnosis

Introduction “Palatal rugoscopy” was proposed in 1932, by a Spanish
investigator named Trobo Hermosa.3
Palatal Rugoscopy has developed as an interesting
and important method for human identification in Palatal rugae (Plica palatinae transverse) refer to the
forensic dentistry in recent years. Palatoscopy or palatal ridges on the anterior part of the palatal mucosa each
rugoscopy is the name given to the study of palatal side of the median palatine raphae behind the incisive
rugae in order to establish a person’s identity.1 The use papilla. Palatal relief design of the dentures may be used
of palatal rugae was recommended as one of the method to compare and identify the individuals.4,5 Several studies
of identification in 1889 by Harrison Allen.2 The done in the past have shown and statistically proved that
term the rugae patterns exhibit hereditary pattern and there
are differences between races and gender. 6-8

Although some longitudinal studies have stated

Corresponding Author: changes in the length and direction of palatal rugae
Dr Swapna B.V with age 9-11, orthodontic influences like extraction of
Associate Professor, Department of Prosthodontics first premolar 12,13, trauma, extreme finger sucking and
Faculty of Dentistry, Melaka Manipal Medical College persistent pressure with orthodontic treatment 14,15 but
Manipal-576104, Karnataka, India stability in shape, direction throughout life have been
Phone: 91 9880359889 extensively documented.16,17,18
Email: [email protected]
118 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 118
118
As both malocclusion and rugae pattern exhibit a 1. Primary >5mm
strong hereditary predisposition, this common feature
2. Secondary 3 to 5mm
led to investigate whether palatine rugae can be used as
an adjunctive diagnostic tool in categorising 3. Fragmentary < 3mm
malocclusions.
The number of rugae falling under the category of
This study was carried out to ascertain whether any primary, secondary and fragmentary rugae was recorded
correlation exists between pattern of palatine rugae in separately for left and right side.
different classes of malocclusion in Malaysian students
thereby helping in diagnosing, intercepting and treating Orientation of palatal rugae: The angle formed
malocclusion in early stage. between mid-palatal raphe and first, second and third
PR were recorded separately for left and right side and
Objectives of the study categorised using classification given by Hauser as:

1. To identify common pattern of PR in the 1. Posteriorly directed rugae (p) - associated with
study negative angles.
population 2. Horizontal/perpendicular rugae (h) - associated
2. To determine the pattern of PR in different classes with angles of zero degrees
of malocclusion. 3. Anteriorly directed rugae (a) - associated with
3. To explore the probability of PR as an adjunctive positive angle
diagnostic tool for classifying malocclusions.
Shape of palatal rugae: The shape of first, second and
third primary rugae were recorded separately for left and
Subjects and Method
right side of each cast from their origin to termination
The present study was performed on 70 dental and classified according to classification given by
and medical Malaysian students between the age Hauser et al as :
group of 19- 23 years in Manipal University following 1. Curved(c): The curved type had a simple crescent
institutional ethical clearance. Informed consent was shape which curved gently.
obtained from the students prior to the participation in
the study. Inclusion criteria were complete complement 2. Straight(s): Straight types ran straight directly
of permanent teeth till second molars, no history of from their origin to termination.
previous extraction of teeth or orthodontic treatment, 3. Wavy (w): The basic shape of the wavy rugae was
no deleterious habits. Exclusion criteria included were serpentine;
students with completed orthodontic treatment or
undergoing orthodontic treatment. Irrespective of 4. Forking (f): Unification occurs when two rugae
gender, the samples were classified into three groups are joined at their origin or termination based on
based on Angle’s classification of malocclusion which, they were of two types:
following intra oral examination. Impression of the fd1: Converging: Rugae with different origins
maxillary arch was made with irreversible hydrocolloid which joined on their lateral portions.
impression material. Casts were poured with type III
dental stone and labelled according to type of fd2: Diverging: Unifications in which two rugae
malocclusion. Landmarks on palatal raphe and PR were began from the same origin but immediately
marked using black permanent marker pen according diverged.
to the classification given by Kapali etal 19 The traced 5. Island (i): The rugae that displayed a definite
palatal rugae were observed for length, orientation, continuous ring formation at the termination was
shape and strength. termed as Island.
Length of PR: The length of the rugae was recorded 6. Irregular (Ir): Broken, irregular pattern of rugae.
using digital vernier caliper from medial end of rugae
to the lateral end (figure 1) and categorised following
classification given by Lysell 9 into
Strength of Palatal Rugae: Based on thickness of rugae were less than 1 in class I malocclusion, however
first, second and third primary rugae strength of were it was more than 1 in class II and class III malocclusion.
classified according to Hauser et al as: The average number of rugae taking into account
a. Strong(s) primary, secondary and fragmentary rugaes were
greatest in Class II malocclusion but almost similar in
b. Medium(m) rest of the classifications. ANOVA depicted significant
c. Weak (w) p-value for primary rugae on right side in all three types
of malocclusion.
Results Table 2 shows the mean of primary, secondary and
Data was collected and statistical analysis was tertiary rugaes in different classes of malocclusion.
performed in SPSS 17.0 (SPSS, Chicago III). The results of Table 3 did not depict any uniform
Descriptive statistics (mean and standard deviation) pattern, orientation or strength for a particular
were determined for the number of palatal rugae malocclusion. The trend of orientation pattern in
(primary, secondary and fragmentary) on each side of Class I from first to third rugae predominantly shifts
mid-palatal raphe for each malocclusion group. The from posterior to horizontal while Class II it was
most predominant pattern, orientation and strength of mostly posteriorly oriented. In Class III horizontal and
primary rugae (first, second and third) in each posteriorly were two most predominant types. The
malocclusion group was studied. P value <0.05 was secondary rugaes exhibited wavy pattern in all three
considered to be statistically significant. types of malocclusion. The strength of rugae in class
Results of Table 1 showed number of primary rugae I and class III malocclusion showed a similar trend
in Class I malocclusion on right side being greater in with the first primary rugae being strong gradually
number with mean 4.41 ± 1.04 as compared to left becoming weak till the third rugae. However in class II
side having mean value of 4.23 ± 1.23. In Class II malocclusion all the rugae were weak.
malocclusion, number of primary rugaes were present The results of Table 4 depicts that class I
more right side with values of 4.5 ± 0.57 and in class III malocclusion showed similar bilateral orientation of all
malocclusion it was more on left side with value of the parameters when compared to other two types of
3.65± malocclusion.
0.81. The mean values of secondary and
fragmentary

Table 1: Mean Scores of types of Rugae according to different class of occlusion

Number Primary Rugae Secondary Rugae Fragmentary Rugae

of casts Right Left Right Left Right Left
Class I Malocclusion 40 4.41 ± 1.04 4.23 ± 1.23 1.35 ± 1.3 0.80 ± 0.8 0.93 ± 1.45 0.76 ± 0.9
Class II Malocclusion 10 4.5 ± 0.57 4±0 0.75 ± 0.5 1.5 ± 1.0 1.75 ± 0.5 1.25 ± 0.9
Class III Malocclusion 20 3.45 ± 1.23 3.65 ± 0.81 1.25 ± 1.06 1.3 ± 1.0 1.25 ± 1.2 0.6 ± 0.8
F 5.704 2.009 0.431 2.364 0.879 0.840
.sig (p value) 0.005* 0.142 0.651 0.102 0.420 0.436

Table 2: Mean scores of Rugae according to malocclusion

Primary Rugae Secondary Rugae Tertiary Rugae

Mean ± SD Mean ± SD Mean ± SD
Class I malocclusion 8.65 ± 1.72 2.15 ± 1.71 1.69 ± 1.92
Class II malocclusion 8.5 ± 0.6 2.25 ±1.2 3 ± 0.82
Class III malocclusion 7.1 ± 1.45 2.55 ± 1.73 1.85 ± 1.42
Table 3: Commonly observed patterns of Rugae according to orientation, strength and shape

Primary Rugae Secondary Rugae Fragmentary Rugae

Left Right Left Right Left right
Orientation P P P H P H
Class I Malocclusion Strength S S S S w w
Pattern C,S S W W W/FDI/FD2 W/FD1/FD2
Orientation P P P P P A
Class II Malocclusion Strength w w w w w w
Pattern W C W W C/FD2 W/FD2
Orientation P H P H H H
Class III Malocclusion Strength S S S S w w
Pattern W S W S C,S,W/FD2 W/FD1/FD2
Orientation: P – Posterior, H - Horizontal, A – Anterior. Strength: s-strong, w-weak
Pattern: C-curved, W – Wavy, S - Straight, FD1 - Fragmented Anteriorly, FD2 - Fragmented Posteriorly

Table 4: Distribution of casts which have similar orientation bilaterally

Cast with bilateral Cast with Bilateral Cast with Bilateral
Posterior Orientation Horizontal Orientation Anterior Orientation
Class I Malocclusion 2 4 1
Class II Malocclusion 1 0 0
Class III Malocclusion 3 4 0
malocclusion. Thomas and Kotze studied the rugae
patterns of 6 South African populations and found that
rugae were unique to each ethnic group and that it can
be used successfully as a medium for genetic research.22

In the present study the average number of primary

rugae has been approximately four in number in
accordance with previous studies.23 In the present study
the number of primary rugae was seen to be greatest
in Class II malocclusion, probably due to difference in
degree of development of maxillary basal arch width and
transverse morphology. Hauser et al. in 1989 that stated
that size of the palate affected rugae development with
Figure 1: Measuring length of the rugae broader palates showing greater rugae development.11
Studies have compared maxillary arch width
Discussion development in normal occlusion and patients with
class II malocclusion and found that the order of normal
It is well-established fact that the palatal rugae once
occlusion having greatest, followed by Class II patients.
formed, do not undergo any change except in length and
However, the number of class II malocclusion in the
remain in the same position throughout individual’s life
present sample size was less as compared to class I and
time.20 Palatal rugae pattern may be precise to racial
class III. The incidence of class II malocclusion is less
groups facilitating the population recognition. 21 In the
in Malaysian population. This can correlated with study
present study rugae patterns of the Malaysian population
done by Arsalan 24 which reported highest incidence of
was studied to check if any co relation existed between
class I malocclusion followed by class III and class
II
being the least. However, to attain a conclusive evidence 2. The number of primary rugae on the right side
of this specific outcome, a larger sample size of Class II were statistically significant in all types of
has to be studied. malocclusion.

The age group of sample in the present study was 3. The most predominant pattern for first, second
around 19-23 years. Studies have proved that orientation and third primary rugae was wavy.
pattern gets established at birth and attain a final feature 4. The number of primary, secondary and
during adolescence. Any change that occurs thereafter fragmentary rugae was greatest in number in
may be in terms of length but not in shape.25 Class II malocclusion when compared to class I
and class III, however it is cannot be considered
In the present study the strength of rugae decreases
statistically significant as the number of sample
from first to third primary rugae in class I and class
size is less.
III malocclusion. This is in accordance with previous
studies of decreasing regularity of rugae pattern, Ethical Clearance: Taken from institutional ethics
disappearance of posterior rugae and strength of anterior committee, Kasturba medical college and hospital,
rugae becoming considerably more pronounced. 23 Manipal

PR number, shape as well as orientation have shown Source of Funding: Self funded
genetic predisposition in previous studies, thus supports
its correlation with different malocclusions having Conflict of Interest: Nil
strong genetic potential.23 Kapali S et al compared the
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DOI Number: 10.5958/0976-5506.2019.01548.1

Effect of McKenzie Approach and Neck Exercises on Forward

Head Posture in Young Adults

Vishnupriya Deshpande1, Khushboo Bathia2, Smita Kanase2, Amrutkuvar Pawar2, Prachi Jain1, Gatha
Patel1
Intern, 2Assistant Professor, Department of Physiotherapy, Krishna Institute of Medical Sciences
1

Deemed
To Be University, Karad, Maharashtra, India

ABSTRACT
Objective: To examine the effects of McKenzie approach, Neck Exercises and combination of both on
Forward Head Posture in young adults.
Method: 30 subjects between of the age group 18-35 years were randomly allocated into 3 groups to
receive McKenzie approach, neck exercise or combination treatment for 3 sessions per week, for 4 weeks.
Outcome assessment was recorded at baseline, 2 weeks and 4 weeks post-treatment.
Results: There were significant differences in all outcome measures after 2 and 4 weeks of treatment within
all 3 groups (p<0.001) except extension, right rotation and right lateral flexion in group A (>0.05), left
lateral flexion and Neck Disability Index in group B (p>0.05) and left lateral flexion in group C (p>0.05).
There were significant differences in Flexion, right rotation, CCFT (p <0.01) and left rotation (p>0.05),
between group A and group B , left rotation (p <0.05) between group A and C, CCFT (<0.001) between
group B and C after 2 weeks of treatment. There were significant differences in flexion (<0.05), left
rotation and right rotation (<0.01) between group A and B after 4 weeks. There were significant
differences in left and right rotation (p <0.01) and CCFT (p <0.05) between group A and B, flexion (p
<0.01) between group A and C, CVA (p <0.05), left and right rotation (p <0.01) and CCFT (p <0.001) from
2nd to 4th week of treatment between group B and C.
Conclusion: Both McKenzie approach and Neck exercises were effective in treating Forward Head Posture
but statistically significant difference was found between groups (A) and (B), (B) and (C) but there was no
significant difference found between groups (A) and (C).

Keywords: Forward head posture, McKenzie approach, Neck exercises, Young

adults
Introduction etc. FHP is one in which the upper cervical convexity is
increased and the lower cervical convexity is decreased
In the modern era, the prolonged uses of mobile
causing anterior weight bearing of the cervical spine1).
phones and computers have lead to a variety of
It is also known as Scholar’s neck, Reading neck or
musculoskeletal disorders, especially related to the
Wearsie neck2).
neck namely, Forward Head Posture(FHP), rounded
shoulders, upper cross syndrome, mechanical neck pain The prevalence of FHP using anterior head
translation in plain radiographs in neck pain patients
was found to be 37%, out of the total subjects
having
Corresponding Author: FHP 58% were females and 42% were males 3). A
Vishnupriya Deshpande review of different observational studies on neck pain
Intern, Faculty of Physiotherapy, around the world showed that its 1 year prevalence
Krishna Institute of Medical Sciences ranged from
Deemed To Be University, 16.5 to 75.1% for the entire adult population4).
Karad–415 110, Maharashtra, India
Phone: +919145332290 To maintain the head in forward position and to
Email: [email protected] counteract the excessive external flexion moment,
there is constant isometric
contraction of the cervical
124 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 124

extensors1) that take over the load of the inactive deep the head remained horizontal without any inclination
neck flexors. This leads to lengthening of the cervical of the head through the movement. Once the end range
extensors whereas shortening and weakness of deep was gained and held momentarily, starting position was
neck flexors causing muscle imbalance5) ultimately achieved again. Retraction was a precursor to any other
leading to injury to the soft tissues. This results in cervical movements. When a good retraction range was
reduced range of motion as well as diffused pain in the achieved, progression was made. The subjects were
neck, scapular and head regions5). Therefore, it is demonstrated and taught self exercises and were advised
important to treat FHP to relieve neck pain, improve to perform these exercises every 2-3 hourly.
posture and increase the range of motion.
Group B. The subjects were given neck exercises
McKenzie approach is one of the most common that included Deep Cervical Flexors strengthening which
therapies used for the management of spinal conditions were performed 10 times, holding each for 20 seconds7)
including dysfunctions like FHP. in which patients are with the subject in supine, head in neutral; nodding
managed with an appropriate repeated loading strategy movement was performed while the therapist palpated
which is progressed according to patient response alongto check whether superficial neck flexors were activated.
with postural correction. Sub-occipitals stretching was done with the subject in
The primary cervical muscles that undergo sitting position; chin retracted and passively flexed until
imbalance are the cervical flexors namely, Deep a stretch was felt, 4 times with hold of 30 seconds were
Cervical Flexors and the cervical extensors namely, done. The subjects were demonstrated, supervised and
Suboccipitals. Literature states that in order to taught self exercises and were advised to perform these
correct the posture and maintain it to prevent exercises every 2-3 hourly.
recurrence, strengthening of deep cervical flexors and
Group C. This group underwent a combination
stretching of sub-occipitals is necessary.
treatment of group A and B simultaneously.

Methodology Outcomes: Photogrammetric method. The subject was

made to stand with neck and shoulder relaxed and the
Participants: Thirty subjects (10 men, 20 women) with C7 was marked using a permanent marker to be used in
FHP within the age group 18-35 years, having neck the quantification process in the angles. The digital
pain since 3 months, anterior weight bearing >15mm camera (Nikon Coolpix 7100TM) was kept on a tripod
in the lateral view of plain radiograph, Pectoralis minor stand 1.5m away from the subject and the height of the
length < 2cm and falling under Dysfunction syndrome
camera was adjusted. All the subjects were
were included while subjects with history of cervical
photographed thrice with a 2-week interval between.
spine surgery, fractures, whiplash injury, rheumatoid
The photographs were then transferred to the laptop
arthritis and cervical disc herniation were excluded. All
(Lenovo G505TM) and the angles were measured by
the subjects were provided with informed consent. The
using KinoveaTM.
subjects were randomly allocated into 3 groups.
Cranial vertical angle (CVA). The angle was made
Interventions: Group A. The subjects in this group
by drawing a horizontal line passing through C7 which
received McKenzie exercises in which exercises were
was parallel to the ground, a line passing through C7 and
repeated 10 times, 3 times /week for 4 weeks6). We
tragus of the ear8).
used the regimen for the management of dysfunction
syndrome under the guidelines of Mechanical Diagnosis Cranial rotation angle (CRA). The angle was formed
and Therapy by the progression of retraction, retraction by the line connecting C7 with the tragus of the ear and
with overpressure, and retraction mobilization, extension the line connecting the tragus of the ear with lateral
and rotation depending on the patient response. The canthus of the eye8).
traffic light guidelines were used for the commencement
or the discontinuation of the treatment. Cervical ROM. For flexion, extension and lateral
flexion range of motion, the patient was asked to be in
Chin retraction was asked to be performed sitting position, the Baseline Bubble Inclinometer™ was
while placed on the vertex of the head. For rotation, with the
the therapist supervised the movement to ensure that patient in supine, the inclinometer was placed on
the
forehead. The pointer was adjusted to 0 degrees, the inter-group analysis for parametric data was done using
respective movement was asked to be performed and the One-way ANOVA while for non-parametric data was
readings were noted accordingly. done by Kruskal-Wallis test. The inter-group multiple
comparison analysis was done using Tukey Kramer
Craniocervical flexion test. The subject was in
multiple comparison test. Statistical significance was
supine with the neck in neutral. The Chattanooga
accepted for the values of p<0.05 at 95% confidence
Pressure stabilizer unit™ was placed underneath the
interval. The analyses were performed using SPSS
cervical lordotic curve. Baseline cuff inflation of
(version 25.0, Chicago, USA).
20mmHg was obtained. The subject was instructed to
perform neck flexion at 5 different pressure levels
progressively (22, Results
24, 26, 28, 30) and hold each level for 10 seconds. There were significant differences in all outcome
A
measures after 2 and 4 weeks of treatment within
30 second rest period was provided between each neck all
flexion9). At the level where the subject could not hold 3 groups (p<0.001) except extension, right rotation
for
and right lateral flexion in group A (>0.05), left lateral
10 seconds or the activation of superficial neck flexors
flexion and Neck Disability Index in group B (p>0.05)
was palpated, the test was stopped and the previous level
and left lateral flexion in group C (p>0.05). There were
of cuff inflation was taken as the reading.
significant differences in Flexion, right rotation, CCFT
Neck Disability Index. In this study, the subjects (p <0.01) and left rotation (p>0.05), between group A
marked the option which was most suited to their and group B , left rotation (p <0.05) between group A
symptoms. The total score was transformed into and C, CCFT (<0.001) between group B and C after 2
percentage points by using the following formula. weeks of treatment. There were significant differences
in flexion (<0.05), left rotation and right rotation (<0.01)
Total score/50 x 100 = %points between group A and B after 4 weeks. There were
significant differences in left and right rotation (p <0.01)
Statistical method: The outcome assessment was
and CCFT (p <0.05) between group A and B, flexion (p
taken at the baseline prior to the treatment after group
<0.01) between group A and C, CVA (p <0.05), left and
allocation, 2 weeks and 4 weeks after the treatment
right rotation (p <0.01) and CCFT (p <0.001) from 2nd to
period. Intra-group analysis was done using Repeated
4th week of treatment between group B and C.
Measures ANOVA. Comparison between baseline
and
2 weeks, 2 and 4 weeks, baseline and 4 weeks was
done by Tukey- Kramer multiple comparison test.
The

Table 1: p and f values of intra-group analysis between all 3 groups

A B C
Variables p Value
F Value p Value F Value p Value F Value
CVA <0.0001 82.63 <0.0001 24.869 <0.0001 166.01
CRA <0.0001 35.15 <0.0001 57.67 <0.0001 128.48
Flexion <0.0001 50.92 <0.0001 26.401 <0.0001 97.80
Extension 0.0071 6.599 <0.0001 53.24 <0.0001 137.35
Left Rotation <0.0001 24.224 <0.0001 25.89 <0.0001 103.95
ROM
Right Rotation 0.0002 13.78 <0.0001 26 <0.0001 51.93
Left Lateral Flexion <0.0001 16.58 <0.0001 29.88 <0.0001 28.66
Right Lateral Flexion 0.0050 7.203 <0.0001 24.515 <0.0001 46.85
25.266 75.13 60.264
NDI <0.0001 <0.0001 <0.0001
(KW Value) (KW Value) (KW Value)
CCFT <0.0001 22.55 <0.0001 37.45 <0.0001 171
CVA: Cranial Vertical Angle, CRA: Cranial Rotation Angle, ROM: Range of motion, NDI: Neck Disability
Index, CCFT: Cranio Cervical Flexion Test
Table 2: p and f values of inter -group analysis between all 3 groups
Pre Test Post Test (2 Weeks) Post Test (4 Weeks)
Variables p Value
F Value p Value F Value p Value F Value
CVA 0.9772 0.024 0.4743 0.768 0.025 4.249
CRA 0.9576 0.0443 0.686 0.383 0.328 1.162
Flexion 0.051 3.339 0.033 3.894 0.004 6.848
Extension 0.751 0.289 0.667 0.411 0.329 1.160
Left Rotation 0.025 4.237 0.045 3.472 0.008 5.805
ROM
Right Rotation 0.019 4.582 0.012 5.195 0.001 8.520
Left Lateral Flexion 0.805 0.218 0.941 0.061 0.286 1.310
Right Lateral Flexion 0.505 0.701 0.187 1.783 0.072 2.906
NDI 0.639 0.455 0.283 1.321 0.115 2.346
CCFT 0.116 2.331 0.126 2.236 0.000 13.042

Discussion assessment of cervical range of motion, a significant

difference seen in group A and B, group B and C in
Sustained bad posture causes stress as well as
cervical flexion and rotation. It was seen that forward
structural changes in the soft tissues. Postural correction
head posture had a relation with reduced cervical range
and appropriate exercises are necessary for preventing
of motion, namely flexion and rotation16). Group C
further complications as well as decreasing the anterior
showed most improvement in flexion and rotation range
weight bearing of the head.
due to which there was maximum reduction in CVA.
In this study, 30 subjects (male to female ratio 1:2)
It was seen that there was improvement in the NDI
diagnosed with Forward Head Posture were taken. A
scores in all the groups but there was no significant
study reviewed 14 independent cohort studies which
difference between the groups. This shows that both the
showed that development of non-specific neck pain
treatment approaches were beneficial when it came to
was associated with female gender while another study
improving quality of life. Supporting this study, it was
showed no gender difference in relation with Forward
noted that using neck exercises led to decrease in NDI
Head Posture10,11).
scores (mean difference 2.2) 17).
In this study, CVA was taken as an outcome
A study saw that subjects demonstrating chronic
measure. This study showed that there was increase in
neck pain had a poorer ability to perform the CCFT 9).
CVA within all the groups, but there was a significant
The subjects in this study initially had a low CCFT
difference in group B and C. A study showed the
score which may be because of increased upper cervical
changes in CVA after incorporating McKenzie exercises
lordosis being developed due to forward head posture.
on FHP for 4 weeks to be significant 12). Another study
At the end of 4 weeks, it was seen that there was a
also had a significant difference after giving McKenzie
significant difference between group A and B, group B
exercises on FHP 13). In a study, examination of the
and C, concluding that solely relying on neck exercises
change in Neck Flexion Angle after neck exercises
did not improve the deep neck flexors strength.
showed a significant difference post test14).

There was a significant difference in CRA within the Conclusion

groups. CRA was shown to have no significant
difference between the groups in this study. It was concluded that McKenzie approach, neck
exercises as well as their combination were individually
A study showed that there is a correlation between effective in reducing forward head posture. Although
CVA with NDI and Range of motion, especially cervical not statistically significant, the combination of both the
flexion and endurance of deep cervical flexors 15). In the treatments got better outcomes that the former.
Source of Funding: This study was funded by Krishna 9. Thomas Tai Wing Chiu et.al. Performance of the
Institute of Medical Sciences Deemed To Be University, craniocervical flexion test in subjects with and
Karad. without chronic neck pain. J Orthop Sports Phys
Ther 2005.35:567-571.
Ethical Clearance: This study was approved by the
institutional ethics committee of KIMSDU. Registration 10. McLean SM et.al. Risk factors for the onset of
was done in Clinical Trials Registry- India with the non-specific neck pain: a systematic review, J
registration no. CTRI/2018/01/011073. Epidemiol Community Health, 2010 Jul; 64(7):
565-72.
Conflicts of Interest: Nil
11. Netaji P et.al. The relationship of forward head
posture and rounded shoulders with neck pain in
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4(2):1451-58. 17. Iqbal ZA, et.al. Effect of deep cervical flexor
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time. Korean Soc Phys Med, 2009, 4: 117-124.
DOI Number: 10.5958/0976-5506.2019.01549.3

Socio-economic, Hygiene and Nutritional Status of Indian

Slums: A Scoping Review

K. Jansi Rani1, S. Kavitha Maheswari2, Sebastian Kot3, A. Hariharasudan4

Research Scholar, Dept. of Food & Nutrition, Mother Teresa University, Kodaikanal, India and Faculty of
1

Nutrition and Dietetics, The Standard Fireworks Rajaratnam College for Women, Sivakasi, India; 2Faculty
of FSM & D, Government Arts College for Women, Nilakottai, India; 3The Management Faculty,
Czestochowa University of Technology, Armii Krajowej 19B, 42-201 Częstochowa, Poland and Faculty of
Economic Sciences and IT, North-West University, Vaal Triangle Campus, PO Box 1174, Vanderbijlpark,
1900, South Africa; 4Faculty of English, Kalasalingam Academy of Research and Education, Krishnankoil,
India

ABSTRACT
In the third millennium, the growth of urbanization is rapid, especially the fast developing country like India
move faster towards urbanization, which is lopsided with the expansion of slums. This scoping review aims
to present the socio-economic, hygiene and nutritional status of the slums in India. The methodology of the
study analyses the previous studies on the selected research problem in back-and-forth method. Through
intense and diverse studies, this paper has arrived at the results that the socio-economic status of the Indian
slums is very low. The hygiene and sanitation of those slums are in need of an immediate call. Above all,
the nutritional status of the slum dwellers, especially the women and children is terrifically low. The authors
also report the lack of studies on the selected topic in the southern part of India and also recommend such
studies to be carried out in the future.

Keywords: Slum; Slum Dwellers; Socio-economic Status; Hygiene and Sanitation; Nutritional Status.
Introduction The term slum speaks volumes about the plight of
the poor and the deprived 7. The slum is an overcrowded
In the third millennium, there is a remarkable
and squalid portion of a district or city or town usually
development in the urban populace 1, 2. The speed of
inhabited by the very poor and downtrodden, who
urbanization has been increasing worldwide 3. The fast
generally inhabit in the debris, dirty and infective areas 8.
developing countries like India 4 move faster towards
Pure air, healthy environment and spacious living places
urbanization, with the average rate of 2% yearly when
are all denied to them.
compare with 0.5% in more developed countries 5. This
growth, however, is not uniform in terms of urbanization According to Article 21 of Indian Constitution,
6
. This rapid urbanization pressures the previously Health is a basic right for every human being, despite
overwrought and dense infrastructure of the cities’ and their socio-economic and cultural status 8, 9. The living
upshots to the formation of slums. condition of an individual has its own impact on one’s
health. Health and nutritious meals is a big question mark
for such people, who struggle for their basic needs of the
day in and day out, facing all kinds of challenges 9. Most
of the slums are situated in vulnerable locations such as
Corresponding Author:
river margins, underneath the over bridges, waterlogged
A. Hariharasudan
areas and road margins etc 7, 10, 11. These people are forced
Faculty of English,
to live in such areas because of their economic condition.
Kalasalingam Academy of Research and Education,
Krishnankoil, India The prime objective of this study is to disclose the
Phone: +919894816754 despairs of the slum dwellers in India. More specifically,
Email: [email protected] the aim of the present study is to explore the
different
129 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 129

forms of their deprivations, sufferings and miseries for taken from the government and non-governmental
basic needs including social, constitutional and projects, books, book chapters, dissertation and thesis
economic rights by reviewing previously published comprise of 4%, and 3% of the studies come from the
studies. web sources.

Socio-economic Status of Slums: Through the diverse

Methodology
studies, it is unveiled that the slum dwellers’ socio-
The study adopts a Scoping Review, which is not a economic condition is very pathetic 14. Many studies
linear process (as typically dictated by the protocol for argue that slums are poverty traps and therefore they do
a systematic review) but a back-and-forth between early not have better financial opportunities. Slum population
studies and new insights and changes in search terms remains deprived, particularly in health, education
and even questions 12, 13. The purpose of the scoping and socio-economic aspects 15. It is disclosed that the
review is to analyze all the studies available on the topic financial status of the families in slums is very poor and
without any restrictions on the studies resourced. it influences their health condition and social status too
Considering this approach, the study has analyzed and 10. From many studies, it is profound that 25 per cent
reviewed the kinds of literature related to slums. of slum families earn less than 2,000 INR and sink
below the poverty line 16. Most of the slum dwellers,
The investigation was done on the review of kinds men work as skill-based workers, in other words daily
of literature, methodologies of various studies were waging labors and most of the slum women are servant
understood, the conclusions and interpretation of many maids. Low socio-economic status of the slum children
studies were collectively reviewed in order to compare is significantly responsible for the specific morbidities
and contrast the results of secondary studies. Thus, the of the same 17.
methodology was mainly comprised of content analysis.
The mentioned analysis was carried out by auditing the The overall socio-economic status of slum dwellers
journals and identifying and scrutinizing the studies that is in miserable condition. Maximum slum dwellers are
were related to socio-economic, hygiene and nutritional deprived of education and almost one-fourth of the slum
status of slums of India. The researchers went through dwellers is non-literate . The utmost number of women
10

the studies and gathered the information on the selected dwelling in the slums is uneducated, illiterate and their
topic. Moreover, from this wide range of searching, it status is also lower. Females are less educated than the
was found that there was no study conducted on the males in many of the slums. A survey study among
selected topic in the Southern part of India. the women slum of Vishakhapatnam discloses that the
percentage of women who have received
undergraduates, secondary education and primary
education is just 2%,
28% and 70% respectively 18.

Hygiene and Sanitation in Slums: To any civilized

man, the slum is a virtual hell and it is unhygienic for
human settlements. These underprivileged people, who
live in such unhygienic environments, are vulnerable
to infections and prone to all infections and as the
consequences easily susceptible to communicable
Figure 1: Percentage of various scoping reviewed diseases. Any area with the inadequacy of safe water,
literatures
inadequate access to sanitation and other infrastructures,
(Source: Authors’ own design) ghastly housing, congestion and insecure inhabited
From the above figure 1, it is understood that the status is an informal settlement. Children from poorest
authors have reviewed various literatures in relation to urban slum are three times more likely to die before
the selected research problem. Through the diverse the age of five than those from wealthiest urban and
study, the authors have identified the handful number of rural areas. Worldwide, the slum dwellers do not have
studies. Out of which, 73% of studies are from the the access to such essential requirements 19. Many
journals, 10% of data are from the reports of various studies strongly profound that the slum households lack
studies, 6% is the following:
z Sturdy home of a permanent nature that gives studies mismatch with these findings by saying that
shelter even in all typical weather conditions there is higher under-nourished boy children rather girls
z Adequate living area wherein not more than and some more state that there is no significant gender
three differential 24, but anyways all the studies significantly
people sharing the same room accept the presence of under-nutrition among the
children of sub-standard settlements. In the scenario
z Inexpensive potable water
of the children less than two years, more than half of
z Sufficient hygiene by means of private or public the children -- 55.7% are under-weight and 42.6% are
lavatory shared by the rational number o f stunted and 36.5% suffers from muscle wasting 25. The
populace whooping fact is that most of the children in the slums
experience Protein Energy Malnutrition (PEM), Iron
z Residential protection, which avoids enforced
deficiency anemia, Iodine deficiency disorders, and
evictions.
Vitamin A deficiency 26.
The major notorious problems in the slums are: (a)
The study by Deka et al. (2016) confirms the
be short of drinkable water (b) no appropriate sanitation
prevalence of anemia in adolescent girls from ten
and waste discarding, domestic as well as public
randomly selected slums and declares that the probable
lavatories (c) mosquitoes and rodents threat (d) lack of
reason for this may be worm infestation and this finding
health services at the locality (e) lack of monetary prop
matches with the findings of Vasanthi et al. 27. The
up for women. A study, which is conducted among the
malnutrition and under-nutrition in the adolescence
slums of Delhi, reveals that 83 per cent toilets are
period is the common nutritional problem in the slum,
contaminated with fecal and other waste manners 20.
which may lead to different types of life-threatening
Admittance to safe drinking water and accessibility to
difficulties during pregnancy. The nutritional status of
sufficient sanitation are necessary to the health of
women is destitute in the poorer socio-economic cluster.
every individual 8. Slum population is posing problems
such as poor housing conditions, overcrowding, reduced In slums, underweight is concerted among women
access to safe water and sanitation and lack of personal in the poorer households 16. Poor nutrition starts before
hygiene21. birth and extends into adolescence and adulthood period
and as a consequence, continues to next generations too.
A study in Mumbai slum shows that water-related
Evidently, malnourished girl children are more likely to
infection is the root for 30% of all morbidity. But, after
remain malnourished during adolescence and adulthood
inculcating the practice of proper hand washing, there
and when pregnant more likely give birth to low birth
are 25% lesser diarrheal episodes, 15% lesser Acute
weight infants 2.
Respiratory tract Infection (ARI) episodes and 27%
lesser sick leave in school 21. The study carried out on
the menstrual hygiene of slum women asserts that more Results and Discussion
than half of the slum women use and reuse cloth instead
The present study brings the socio-economic,
of using disposable sanitary pads during menses and the hygiene and nutritional status of the slum dwellers in
additional fact is those women have more prevalence of India into the limelight by analyzing the previous studies
STD/RTI (Sexually Transmitted Disease/Reproductive using scoping review method. It is understood that slums
Tract Infection), when compared to those women using are without essential amenities, occupied by uneducated
disposable sanitary pads 22. Thus, two things can be and altogether, their state of living is very pathetic. They
understood from the intense review of the diverse studies: are not given much consideration towards their health
Firstly, the hygiene and sanitation condition of most of and their children’s health and thus, there are more
the slums in the nation is in a dangerous condition with illnesses and sick among slum individuals. Many studies
poor livelihoods, which also demeans the ecology. stand as proof for the fact that poor sanitation, the
Secondly, though the hygiene and sanitation are worst, it nonexistence of toilets, open poo, debased drinking
can be reversed by appropriate intervention policies by water, and so forth are the probable explanations
the governmental and the non-governmental behind the sickness of ladies and children in slum
organizations. ranges. Because of these reasons, the hygiene and
nutritional status of Indian slum
Nutritional Status of Slums: The occurrence of under-
nutrition is higher among girls than that of boys 23. Some
regions is a somber issue. Crucially, the authorities need urban slums of Guwahati city, Assam, India. Int J
to make essential strategies, because 70% of the slum of Community Med and Pub Health. 2016;3(8):
dwellers respond negatively while asking whether they 2169-2173.
feel that their families eat a balanced diet and receive
proper nutrition and are satisfied or happy with their 3. Shukla M, Agarwal M, Rehman HM, Yadav K,
living condition and livelihood 18. These people with Imchen T. Housing and sanitary conditions in
their eyes opened wide, hands stretched long, waiting for slums of Lucknow, capital of Uttar Pradesh. Int J
the helping hands from the governmental and the non- of Med Sci and Pub Health. 2015;5(6): 1153-1157.
governmental agencies. 4. Hariharasudan A, Gnanamony SR, Rajaram S. An
eye view of technical English language among
Through intensive reviewing of many studies on the
engineering students in southern Tamil Nadu
selected research topic, the authors discover the big gap
(India): an analysis in the postmodern era. Global J
in the literature, where is the lack of studies undergone
of Business and Soci Sci Review. 2017;5 (1): 9-17.
in the southern part of India.
5. Jaiswal V. Water and sanitation situation in urban
Conclusion and Implications slums of India: evidence from NSSO. J of Health
Sci and Research. 2016;6(5): 248-253.
From the keen audit, this work tries to throw light
6. Mahabir R, Crooks A, Croitoru A, Agouris P. The
on another side of the coin -- the darker shades of the
study of slums as social and physical constructs:
nation, which really needs to be emphasized and thus,
challenges and emerging research opportunities.
it concludes that the socio-economic, hygiene and
Reg Stud, Reg Sci. 2016;3 (1): 399–419.
nutritional status of slums of India are in very pathetic
condition moreover, many studies are not published on 7. Hanchett S, Akhter S, Khan MH, Blagbrough
the slums of South India, particularly in Tamil Nadu SM, Vicky. Water, sanitation and hygiene in
and covering all theses context in a single study. By Bangladeshi slums: an evaluation of the water
identifying this gap, the present study motivates the aid – Bangladesh urban programme. Environment
researchers to get interested with more society-oriented and Urbanization. 2003;5 (2): 43-56.
studies especially about such underprivileged and the 8. Sau A. A study on water supply and sanitation at
economically downtrodden people. The researchers a slum in Kolkata. International J of Med Sci and
believe that this study may motivate further researches Pub Health. 2016; 6(3): 634-637.
in socio-economic condition, hygiene and nutritional
status of the slums of Tamil Nadu. 9. Rani JK, Maheswari SK. A systematic review on
the hygiene and nutritional status of the women
Conflict of Interest: The authors declare no conflicts of living in the slums of India. J of Adv Research in
interest. Dynamical and Control Sys 2017;7: 303-313.

Source of Funding: This research received no external 10. Kaviarasu SJ, Xavier GG. Status of women’s
funding. health in urban sub-standard settlements of
Chennai, Tamil Nadu state, India. European Acd
Ethical Clearance: An ethical clearance is not required Research. 2015;2(11): 14473-14483.
for this study.
11. Jogdand SS, Naik DJ. Pattern of behavior
problems amongst the urban slum dwellers
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DOI Number: 10.5958/0976-5506.2019.01550.X

Study of Correlation between Serum Lipid Profile and Thyroid

Function in a Tertiary Care Hospital

Aryankumar1, Ajit Sontakke2, Sangita Patil3, Dhirajkumar Mane4

1
2ND year M.B.B.S. Student, 2Professor & Head, 3Associate Professor, Department of
Biochemistry,
4
Statistician, Krishna Institute of Medical Sciences, Karad, Maharashtra

ABSTRACT
Introduction: Hypothyroidism is strongly related to increased risk of cardiovascular diseases due to
its potential association with atherogenic lipid profile. Hypothyroidism also can even cause premature
atherosclerosis. Untreated hypothyroidism is the most common cause of reversible hyperlipidemia.
Method: Blood samples received from either OPD or IPD in plain and EDTA vacutainer was separated
from blood to plain vacutainer by centrifugation at 3000rpm for 10 minutes. For HbA1c EDTA vacutainer
samples are used. By using different methods serum urea, creatinine estimated on fully automated
analyzerEM360.
Results: Age wise distribution show a more number in <50years group, indicating early occurrence of
hypothyroidism, might be because of more stressed lifestyle resulting in deranged thyroid metabolism. Our
study shows in gender wise distribution more number for female subjects, since hypothyroidism is more
common in females. Regarding VLDL levels, significant correlation was found with T4, indicating
changing impact on triglycerides metabolism with severity of hypothyroidism.Since our objective of the
study is to establish a correlation between lipid profile and TSH as our finding show negative correlation
TSH and total cholesterol and LDL cholesterol.
Conclusion: Since our objective of the study is to establish a correlation between lipid profile and TSH
as our finding show negative correlation TSH and total cholesterol and LDL cholesterol. But this need
more research work on this aspect of independent correlation of TSH and total cholesterol. This can further
help to diagnose early hypothyroidism with only two parameters TSH and total cholesterol, if proved and
thoroughly researched.

Keywords: Hypothyroidism, thyroxin,

hyperlipidemia.
Introduction overall metabolism and significantly influences serum
cholesterol level.1 Hypothyroidism is strongly related
Thyroid hormones regulate metabolism of number
to increased risk of cardiovascular diseases due to its
of biochemical parameters. Because of this, disorders of
potential association with atherogenic lipid profile. Since
thyroid gland are the most common endocrine disorders.
hypothyroidism has a great impact on lipid metabolism,
Diseases of thyroid gland affect lipid metabolism,
especially serum cholesterol level and other risk factors
since thyroxin favors lipolysis and lipid turnover.
which can result in complications like atherosclerosis,
Hypothyroidism is associated with increased cholesterol
obesity and hypertension responsible for cardiovascular
levels because of defective transport by HDL.TSH
disease. Thyroid gland is regulated by TSH, which is
stimulates thyroid hormones synthesis and
produced by pituitary gland, present at the base of brain.
controls
This scenario aroused interest for this study to find
out relationship of especially TSH with lipid profile and
Corresponding Author: other complications as cardiovascular disease2.
Ajit Sontakke
Professor & Head, Department of Biochemistry, A number of studies reported that high level of
Krishna Institute of Medical Sciences, TSH has deleterious effect on serum lipid levels but
Karad, Maharashtra
134 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 134

this study is still in debate because many studies are NAME OF

not supporting this correlation as it is influenced by METHODS USED
PARAMETER
factors like BMI, age, gender etc. But several studies SERUM T3 FUOROIMMUNOASSAY
established well inverse relation between cholesterol SERUM T FUOROIMMUNOASSAY
with thyroxin but not much research work is available in 4
SERUM TSH FUOROIMMUNOASSAY
Indian population. Also there is not much research work
SERUM TOTAL
available on independent correlation between TSH and COLORIMETRIC
CHOLESTEROL
cholesterol level.
SERUM
COLORIMETRIC
One study has confirmed that TSH is independent of TRIACYLGLYCEROL
thyroid hormones, as TSH can up regulate the SERUM HDL
COLORIMETRIC
expression of hepatic 3-hydroxy-3-methyl glutaryl CHOLESTEROL
coenzyme A reductase which is a rate limiting enzyme SERUM VLDL COLORIMETRIC
in cholesterol synthesis. This indicates there might be an SERUM LDL
COLORIMETRIC
independent correlation between TSH and cholesterol CHOLESTEROL
level2,3.
For all parameters, controls from BIORAD run on
same machine before analysis to check the quality. Even
Material and Method
external quality control program participated, results
This study was conducted in tertiary hospital, are excellent. Data for 287 patients, diagnosed cases
biochemistry laboratory after obtaining approval of hypothyroidism collected during two months study
from institutional ethics committee. Since this is a period. Statistical analysis was done by using software
retrospective study, data collected from the records of INSTA-STAT.
tertiary care hospital for two months study period.

Results

Table 1: Age & Gender Wise Distributions of

Subjects
Age (No.) % Gender No. of Participants %
≤50yrs (158) 55.05 Males 88 30.66
>50yrs (129) 44.94 Females 199 69.33
Total 100 Total 287 100

The total number of subjects included is 287. The number of subjects in ≤50 years group is 158, number is 129
in >50 years group, number of females is 199 while for males it is 88, indicating more number of females suffering
from hypothyroidism.

Table 2: Gender wise Comparison of T3, T4, TSH

Study Variables Gender N Mean SD t-value p-value
Males 88 92.06 66.70
T3 -0.23354 0.815501
Females 199 94.19 75.29
Males 88 9.22 15.22
T4 -2.04843 0.0414
Females 199 6.83 4.49
Males 88 6.50 20.96
TSH -0.2297 0.818484.
Females 199 5.90 19.61
T3- The t-value is -0.23354. The p-value is .815501. The result is not significant at p < .05.
T4- The t-value is -2.04843. The p-value is .0414. The result is significant at p < .05.
TSH- The t-value is -0.2297. The p-value is .818484. The result is not significant at p < .05.
Table 3: Gender wise comparison of Lipid Profile
Study Variables Sex N Mean SD t-value p-value
Males 88 152.55 84.95
TG 0.4760 0.6344
Females 199 147.48 82.52
Males 88 169.61 52.86
Cholesterol 0.9027 0.3674
Females 199 162.75 63.73
Males 88 48.23 22.25
HDL 0.1533 0.8782
Females 199 47.86 17.94
Males 88 95.09 51.08
LDL -0.3757 0.7074
Females 199 92.10 68.30
Males 88 30.73 17.81
VLDL 0.6190 0.4978
Females 199 29.57 16.46
TG - The t-value is 0.47602. The p-value is .634411. The result is not significant at p < .05.
Cholesterol- The t-value is -0.90271. The p-value is .367414. The result is not significant at p < .05.
HDL- The t-value is 0.15337. The p-value is .878208. The result is not significant at p < .05.
LDL- The t-value is -0.3757. The p-value is .707413. The result is not significant at p < .05.
VLDL The two-tailed P value equals 0.6190 t = 0.4978 The result is not significant at p < .05.

Table 4: Correlation between T3 and Lipid Profile

T3MEAN 93.53S.D. ± 72.73
T3 vs. Lipid Profile
Mean S.D. ± Pearson Correlation P value
TG 149.1376 83.32481 0.0086. 0.8820
Cholesterol 164.896 60.63439 -0.082 0.1565
HDL 47.97987 19.39503 -0.0055 0.9312
LDL 93.04027 63.44663 -0.0901 0.1198
VLDL 29.93266 18.0534 0.0127 0.8286
TG: The value of R is 0.0086.Although technically a positive correlation, the relationship between variables is
weak P-Value is .882077. The result is not significant at p < .05.
Cholesterol: The value of R is -0.082.Although technically a negative correlation, the relationship
between
variables is weak P-Value is0 .1565. The result is not significant at p < .05.
HDL: The value of R is -0.0055.Although technically a negative correlation, the relationship between variables
is weak P-Value is 0.9312 the result is not significant at p < .05.
LDL: The value of R is -0.0901.Although technically a negative correlation, the relationship between variables
is weak P-Value is 0.1198 the result is not significant at p < .05.
VLDL: The value of R is 0.0127.Although technically a positive correlation, the relationship between variables
is weak P-Value is 0.8286 the result is not significant at p < .05.

Table 5: Correlation between T4 and Lipid Profile

T4 vs. Lipid T4 MEAN 7.582651S.D.9.341445

Profile Mean S.D. ± Pearson Correlation P value
TG 149.1376 83.32481 0.1454 0.1169
Cholesterol 164.896 60.63439 0.0877 0.1296
Conted…
HDL 47.97987 19.39503 -0.0057 0.9312
LDL 93.04027 63.44663 0.0745 0.1981
VLDL 29.93266 18.0534 0.1458 0.01146
TG :The value of R is 0.1454.Although technically a positive correlation, the relationship between variables is
weak P-Value is 0.1169. The result is not significant at p < .05.
Cholesterol: The value of R is0.0877.Although technically a positive correlation, the relationship
between
variables is weak P-Value is0 .1296. The result is not significant at p < .05.
HDL: The value of R is -0.0057.Although technically a negative correlation, the relationship between variables
is weak P-Value is 0.9312 the result is not significant at p < .05.
LDL: The value of R is0.0745.Although technically a positive correlation, the relationship between variables is
weak P-Value is 0.1981 the result is not significant at p < .05.
VLDL: The value of R is 0.1458, a positive correlation; the relationship between variables is significant as
P-Value is 0.01146 the result is at p < .05.

Table 6: Correlation between TSH and Lipid Profile

TSH vs. Lipid TSH MEAN 6.110527 S.D. ± 20.04

Profile Mean S.D. ± Pearson Correlation P value
TG 149.1376 83.32481 -0.086 0.1372
Cholesterol 164.896 60.63439 -0.1188 0.0411
HDL 47.97987 19.39503 -0.0375 0.5232
LDL 93.04027 63.44663 -0.0828 0.1565
VLDL 29.93266 18.0534 -0.0908 0.1198
TG: The value of R is -0.086.Although technically a negative correlation, the relationship between variables is
weak P-Value is 0.1372. The result is not significant at p < .05.
Cholesterol: The value of R is -0.1188.Although technically a negative correlation, the relationship
between
variables is weak P-Value is 0.0411. The result is significant at p < .05.
HDL: The value of R is -0.0375.Although technically a negative correlation, the relationship between variables
is weak P-Value is 0.5232 the result is not significant at p < .05.
LDL: The value of R is-0.0828.Although technically a negative correlation, the relationship between variables
is weak P-Value is 0.1565 the result is not significant at p < .05.
VLDL: The value of R is -0.0908, a negative correlation; the relationship between variables is significant as
P-Value is 0.1198 the result is at p < .05.

Discussion considerable improvement of the lipid profile 4,5. From

this study it can be concluded that hypothyroidism is
Hypothyroidism increases the oxidation of plasma
associated with lipid disorders that are characterized
cholesterol mainly because of an altered pattern of
by normal or lightly elevated total cholesterol levels,
binding and due to the increased levels of cholesterol,
increased LDL-cholesterol and lower HDL-cholesterol
which presents substrate for oxidative stress.
Hypothyroidism is often accompanied by diastolic Age wise distribution show a more number
hypertension that, in conjunction with the dyslipidemia, in <50years group, indicating early occurrence of
may promote atherosclerosis. However, thyroxin hypothyroidism, might be because of more stressed
therapy, in a thyrotropin (TSH) suppressive dose, lifestyle resulting in deranged thyroid metabolism.
usually leads to a Our
study shows in gender wise distribution more number triglyceride level elevated in hypothyroid patients. So,
for female subjects, since hypothyroidism is more our study findings were consistent with the previous
common in females. In one study, researchers did not studies done by other investigators like Keyes WG 9and
find that total cholesterol level was higher in women Abrams JJ10. Venditti P 11have stated decreased activity
with subclinical hypothyroidism than euthyroid women6. of LDL receptors as the main cause of
hypercholesterolemia in hypothyroidism. Serum
Gender wise comparison of T3,T4, shows decrease concentrations of high density lipoprotein cholesterol
in case of females as well as males but within normal was reported to be higher among newly diagnosed
ranges with significance in case of T4 ascompared to hypothyroid patients (subclinical or clinical) whereas
T3.This indicating severity of hypothyroidism is more serum concentrations of HDL cholesterol were
in females than males.Comparison of TSH show a rise in significantly lower among euthyroid and previously
both genders but within normal. Lipid profile reported hypothyroid cases who were on thyroxin
comparison in males and females show increase in case replacement therapy 12. Studies done by
of males. This might be because of more utilization of Michalopoulou showed average serum concentration of
cholesterol and other lipids for synthesis of female HDL higher in subclinical or clinical hypothyroidism,
hormones like estrogen and progesterone. similar to our finding. Abrams J J& Grundy S M13 has
shown in their studies reduction of HDL cholesterol in
When T3 correlated with lipid profile it’s showing
hypothyroidism13. So, decrease in HDL cholesterol level
weak positive correlation only with triglycerides,since
in our study might be due to increased activity of CETP
decrease in T3 is very little and within normal limits
and lipoprotein lipase in hypothyroid patients.
therefore not much increase in triglycerides. Remaining
all parameters in lipid profile show negative correlation There was no significant difference in serum total
and increase in lipid profile is within normal range. cholesterol concentrations among the groups, males
Similarly when T4 correlated with lipid profile its and females. But the different pattern of decreasing
showing positive correlation as decrease inT4 and cholesterol with increasing severity of hypothyroidism
increase in lipid profile is within normal
revealed in this study. This is further supported by our
range.Correlation with VLDL is significant, only HDL
finding of no correlation of HDL with T3, T4.This might
showing negative correlation with T4, but within
be due to our small sample size.
normal limits. TSH show negative correlation with all
lipid profile parameters, in case of cholesterol it is Regarding VLDL levels, significant correlation
significant. This might be because of increased TSH,there
was found with T4, indicating changing impact on
is rise in T3,T4 regulating the lipid profile resulting in
triglycerides metabolism with severity of
decreased levels but within normal limits. hypothyroidism. It is claimed that thyroid hormones
Hypothyroidism is a common metabolic disorder. facilitate the LPL activity , but deficiency of thyroid
14

The prevalence of primary hypothyroidism is 1:100, hormones to inhibit LPL probably follows a ceiling
but it may be 5:100 if patients with subclinical point beyond which further reduction of thyroid
hypothyroidism (normal T4, raised TSH). According hormones does not cause further inhibition of LPL. In
to a study done by Ajay Arsana 7, hypothyroidism is a our study T4 has shown negative correlation with HDL
common disorder with a prevalence rate up to 20%. In cholesterol level. Positive correlation was found
another cross-sectional study on twelve hundred and between serum T4 level and serum total cholesterol
twelve subjects of both sexes and age 20-60 years, the level, serum triglycerides, LDL and significant
incidence of subclinical hypothyroidism was 19.7%. In withVLDL. Total cholesterol and LDL cholesterol were
our study, mean total cholesterol, LDL cholesterol and found to maintain negative correlation with serum TSH.
triglycerides were found slightly increased whereas TSH was found to show significant negative correlation
HDL cholesterol not decreased in cases of with serum cholesterol.Significant negative correlation
hypothyroidism. JUNG8 found mean plasma total of TSH with cholesterol level and negative correlation
cholesterol and LDL cholesterol levels elevated in of TSH with triglycerides appear to make a sense of
hypothyroid cases than in normal controls. In another functional disharmony between T4 and TSH and,
study, average serum total cholesterol level was found therefore, a large scale study is recommended to make it
elevated in primary and secondary hypothyroidism. clear. Results of our study suggest the findings of mild
Keyes &Heimbergfound dyslipidemia in hypothyroid patients.
Since our objective of the study is to establish a patients attending an outpatient lipid clinic.
correlation between lipid profile and TSH as our finding Thyroid 1999;9:365-368
show negative correlation TSH and total cholesterol and
5. Guyton AC, Hall JE. The thyroid
LDL cholesterol. But this need more research work metabolic
on aspect of independent correlation of TSH and
this hormones. In: Textbook of medical
total
cholesterol. This can further help to diagnose early physiology.
hypothyroidism with only two parameters TSH and 10th edn. New York: W B Saunders
total cholesterol, if proved and thoroughly researched. 6. Pearce EN. Hypothyroidism and dyslipidemia:
So, our study is consistent with some of the studies and Modern concepts and approaches. CurrCardiol
inconsistent with the others. A large scale study on overt Rep. 2004;6:451–6. [PubMed]
hypothyroid patients is recommended to come to a final 7. Ajay Asranna, R. S. Taneja, and
conclusion. It does however have some limitations; BinduKulshreshtaDyslipidemia in subclinical
measurements of TSH and T4 and lipid profiles were hypothyroidism and the effect of thyroxine on
performed just once. Our results must be cautiously lipid profileIndian J EndocrinolMetab. 2012 Dec;
interpreted for the general population. This study is not 16(Suppl 2): S347–S349.
a prospective study and therefore it demonstrates only
association and not causation of various variables. 8. Jung KY1, Ahn HY2, Han SK3, Park YJ4, Cho
BY2, Moon MK5.Association between thyroid
Ethical Clearance: Taken from Institutional function and lipid profiles, apolipoproteins, and
ethics high-density lipoprotein function.JClinLipidol.
committee 2017 Nov - Dec;11(6):1347-1353. doi: 10.1016/j.
jacl.2017.08.015. Epub 2017 Sep 4.
Source of Funding: ICMR
9. Keyes WG, Heimberg M. Influence of thyroid
Conflict of Interest: NIL status on lipid metabolism in the perfused rat
liver. J Clin Invest 1979;64:182-190.
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DOI Number: 10.5958/0976-5506.2019.01551.1

Self Management and Knowledge among People with Type 2

Diabetes

Aldrin Vas1, Elsa Sanatombi Devi2, Sudha Vidyasagar3

PhD Scholar, 2Professor, Manipal College of Nursing, Manipal Academy of Higher Education,
1

Manipal;
3
Professor, Department of Medicine, Kasturba Hospital Medical College, Manipal

ABSTRACT
Purpose: The purpose of the study was to assess the knowledge and self management among people with
type 2 diabetes.
Method: This study was carried out among 180 people with type 2 diabetes who admitted to tertiary care
hospital at Udupi from June 2015 to January 2016. Data collected were basic demographic information and
clinical items like HbA1c and BMI, knowledge, self management among people with type2 diabetes. Self
management is assessed with diabetes self management questionnaire.
Results: This study revealed moderate level of self management among 95% participants and
moderate
level of knowledge was observed among 85% participants.
Conclusion: Considerable number i.e. 15% had inadequate knowledge regarding diabetes and its
management which calls for appropriate intervention focusing on enhancing self management ability of
people with type 2 diabetes.
Summary Statement:
What is already known about this topic?
z Self management is essential in diabetes management.
z Knowledge is the crux of effective management of diabetes.
What this paper adds?
z This study focuses on various aspects of self management among people with type 2 diabetes.
z Awareness about different dimensions of self management will help to design interventions to improve it.
The implications of this paper
z Shift of focus from symptomatic care to holistic approach where overall quality of life will be
the
goal of intervention.
z Innovative approaches to strengthen the ability of self management of their condition to maintain a
good quality of life of people with type 2 diabetes

Keywords: Type 2 diabetes; Self management, Diabetes

knowledge

Email: [email protected]
Corresponding Author:
Dr. Elsa Sanatombi Devi
Professor, Manipal College of Nursing,
Manipal Academy of Higher Education, Manipal-
576104
Phone: +91 9739864293
Introduction

New case of diabetes is diagnosed every 40

seconds1. Across the world approximately 415 million
people are living with diabetes and it may increase to
642 million by the year 2040 Developing countries
constitutes 75% of them. About 69.2 million of them
live in India and
140 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 140

estimated number for South East Asia is 78.3 million2. criteria. This study included 180 people with type2
In India due to diabetes 1.1 million deaths occurred and
in South East Asia it is 1.2 million3.

In urban India about 8.7% is the prevalence

rate.
40-59 years is the age group which constitutes majority,
which is found to be a decade earlier with comparison
of western population. This means young people are
affected with diabetes in their productive years of their
life4, which poses a risk of diabetes related
complications, since they have to live with diabetes for
longer duration. From this perspective self management
plays pivotal role in adopting healthy lifestyle and
preventing or delaying diabetes related complications
and there by leading a good quality of life.

Self management poses a challenge, due to the

complex nature of diabetes. However patients need to be
supported and empowered to maintain the self
management behaviours5. Behavioral change oriented
patient empowerment will aid them to manage their
condition with effectiveness6. Self-management
programmes acts as a foundation for the empowerment
approach7. Since people with type 2 diabetes take
responsibility in managing their condition, the cost
effectiveness of health care may also be evident in self-
management.

Knowledge, attitude and self-management ability

influences the quality of life of people with type 2
diabetes 8. Understanding disease and its management
are the major factors that influence self-management and
glycaemic control9. Diabetes education can be effective
if we are aware of their knowledge, attitude and practice
10
. Success of management of chronic disease is
associated with patient education11, Self-management
education found to be effective in behavior
modification12 and even in old age people in improving
knowledge and treatment adherence13, 14. Diabetes
management can be improved by focusing on self care
activities15. This study aimed to assess the knowledge
and self management among people with type 2
diabetes.

Method
Study Design: A descriptive survey design was used to
determine the knowledge and self management among
people with type 2 diabetes

Setting and Sample: This study was conducted in

Kasturba hospital, Manipal from June 2015 to
January
2016. Samples were selected after satisfying
inclusion
141 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 141
diabetes who were admitted in the medical wards.
Inclusion criteria were concerning age 30 years and
above, diagnosed at least 3 months or more, language
Kannada, voluntary participation in the study, whose
HbA1c is 6% and above.

Ethical Consideration: Clearance obtained from

institutional ethical committee (IEC) and written
informed consent from the people with type2 diabetes
who are under study. IEC approval no: ECR/146/Inst/
KA/2013

Instruments
Data Collection: Data collection was done thorough
questionnaires which were translated to Kannada, the
regional language. Instruments used in the study were
demographic proforma, diabetes knowledge questionnaire
and diabetes self management questionnaire.

Demographic Proforma: Demographic proforma

consisted items like age, gender, religion, dietary habit,
education, family monthly income, occupation, and
clinical items like duration of illness, onset, regular
check up, BMI and HbA1c.

Diabetes Knowledge Questionnaire: This

questionnaire
was developed by the investigator which is made up of
20 multiple choice questions (MCQ’s) on diabetes and
its management which includes diet, physical activity,
foot care and diabetes related complications. Scoring
was done as ‘1’ mark for right answer and ‘0’ mark
wrong answer. Tool was validated by panel of seven
experts i.e. three were from the field of medicine, three
were from the field of medical surgical nursing
speciality and one was from psychiatric nursing
specialty. After validation tool was assessed for its
reliability and it was found to be r (20) = 0.88 which
was statistically significant. This indicates that the tool
was reliable.

Self Management Tool: Diabetes self management

questionnaire developed by Andreas Schmitt et.al. was
used in the study with authors’ permission to collect
self care activities associated with glycemic control.
Diabetes self management questionnaire consists of
four subscales i.e. 5 items about glucose
management,
4 items about dietary control, 3 items about physical
activity, 3 items about health-care use and one item on
overall rating of self-care. Items were scored 0 to 3,
maximum possible score was 48 and minimum was 0.
The self management scores were categorized into good
(33-48), moderate (17-32) and poor (0-16)16.
All the tools were in English and were translated a year, 51.1% had information on diabetes. 8 gm% of
to regional language Kannada. Translation was done HbA1c was observed among 52.2% and 53.3% had BMI
by a professional language translator. Accuracy of the more than 25.
translation was ensured by retranslating it back into
English. Pre testing of the Kannada versions of tools Self management and knowledge among people with
were done by administering it to 20 people with type 2 type 2 diabetes
diabetes. No modifications were done as there were no
confusions expressed by the participants.

Data Collection
From June 2015 to January 2016 data collection was
done in medical wards. It is convenient sampling
technique was used to collect the data. Permission was
obtained from medical superintendent of the hospital.
Informed consent was taken from the study participants. A
total of 180 people with type 2 diabetes participated in the
study.
Figure 1: Self management among people with type
Data Analysis 2 diabetes n = 180

As per the study objectives data analysis and

interpretation was done using descriptive and inferential
statistics with the use of SPSS 16 version.

Results
Sample Characteristics: Sample characteristics reveals
that 50 to 69 years is the age group constitutes the
majority (57.8%) of the patients. 67.2% were males,
92.8% were Hindus, for 67.2% participants schooling
was not more than high school, 86.7% were married,
Figure 2 : Diabetes knowledge among people with
5001 to 10,000 Indian Rupees was monthly family
type 2 diabetes n = 180
income for 58.3% and 60% were non vegetarians.
Pie chart on self management (Figure 1) and
About 41 to 50 years is the age of onset diabetes for diabetes knowledge (Figure 2) among people
31.7% and 77.8% of them had diabetes for more with type 2 diabetes.
than
1 year. 49.4% had thrice or more regular check up
in
Table 1: Self management with regard to different domains n = 180

Max. possible Std. Std.

Self management Minimum Maximum Mean Median
score deviation error
Glucose management 2 12 15 7.255 2.050 7 0.152
Dietary control 1 10 12 5.838 1.846 6 0.137
Physical activity 0 9 9 4.361 1.726 4 0.128
Health-care use 0 9 9 4.394 1.838 5 0.137
Overall rating of self-care 0 3 3 1.361 .955 1 0.071
Over all self management 13 31 48 23.21 3.892 23.5 0.290
Self management among people with type 2 diabetes was assessed in 4 different domains. Mean and standard
deviation of glucose management is 7.255 ± 2.050, dietary control is 5.838 ± 1.846, physical activity is
4.361 ±
1.726, health-care use is 4.394 ± 1.838, self-care rating is 1.361 ± .955 and over all self management 23.21 ± 3.892
found to be moderate among people with type 2 diabetes. About 95% of the study participants had moderate level of
self management, for remaining 5% self management was at poor level and no study participants were found with
adequate level of self management which stresses the need for an intervention to improve self management.

Table 2: Diabetes knowledge with regard to different domains n = 180

Max. possible Std. Std.

Diabetes knowledge Minimum Maximum Mean Median
score deviation error
Diabetes in general 0 5 5 2.25 1.133 2 0.119
Diet 0 4 4 1.61 0.899 2 0.094
Physical activity 0 2 2 0.81 0.644 1 0.067
Management 1 8 9 3.81 1.505 4 0.158
Over all diabetes
2 13 20 8.48 2.089 8.5 0.217
knowledge
Knowledge among people with type 2 diabetes was In present study association was found between
assessed in 4 different domains. Mean and standard knowledge and gender and family monthly income.
deviation of diabetes in general is 2.25 ± 1.133, diet Similar results were seen in study conducted by Jackson
is 1.61 ± .899, physical activity is 81 ± .644, diabetes IL, 2014 which revealed association between Self-care
management is 3.81 ± 1.505 and overall knowledge knowledge and duration of diabetes, educational level
is 8.48 ± 2.089. Knowledge about diabetes and its and income17. This study revealed that 15% had poor
management among people with type 2 diabetes is found level of knowledge regarding diabetes and its
to be moderate among 85% of the study management. Diabetes knowledge was at poor level
participants, among people with diabetes and in general
15% found to be inadequate and no study participant population, which calls for immediate educational
had adequate knowledge regarding diabetes and its interventions specially focused on risk factors18, 19.
management which calls for an intervention. Education programmes may be effective in addressing
critical gaps in patients knowledge20. Contribution of
Association between self management, diabetes educational intervention was evident in enhancing the
knowledge and selected variables: Significant quality of life people with type 2 diabetes and their
association was found between self management and family21.
regular check up (P=.001) and information about
diabetes (P=.029). No association was found with items Patients’ knowledge and practice are the key
like age, gender, religion, dietary habit, education, factors which influence self-care behavior; hence there
family monthly income, occupation and clinical items is a need in developing countries for effective diabetes
like duration of illness, onset, BMI and HbA1c. education14 and self-management programmes on
regular basis7. A study conducted by Kumpatla S, 2010
Significant association was found between revealed that HbA1c awareness had a positive impact
knowledge and gender (P=.017) and family monthly on controlling blood glucose level22 and better self-
income (P=.024). No association was found with items management behavior was evident23. Better self-efficacy
like age, religion, education, occupation, dietary habit was observed among those who had higher knowledge,
and clinical items like onset, duration of illness, regular attitude, and perception scores and it is resulted in better
check up, HbA1c and BMI. self care behavior24.

Discussion Conclusion

A study conducted by Kueh Y H, 2015 shown This study revealed about the level of diabetes
diabetes knowledge and self-management essential knowledge and self management among people with
aspects in maintaining quality of life of people with type type 2 diabetes with respect to various domains.
2 diabetes8. Understanding knowledge and practice becomes
essential in effective management of diabetes. 10. Shah VN, Kamdar PK, Shah N. Assessing the
Strategies to enhance knowledge regarding diabetes knowledge, attitudes and practice of type 2
and its management and translation of that knowledge diabetes among patients of Saurashtra region,
into practice specifically self management skills will Gujarat. 2017;29(3):118–22.
empower people with type 2 diabetes to lead a good
11. Karakurt P, Kaşıkçı MK. The effect of education
quality of life.
given to patients with type 2 diabetes mellitus
Conflicts of Interest: Nil on self-care. Int J Nurs Pract [Internet].
2012;18(2):170–9.
Source of Funding: Nil
12. Moriyama M, Nakano M, Kuroe Y,
Nin K, Niitani M, Nakaya T. Efficacy of a self-
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DOI Number: 10.5958/0976-5506.2019.01552.3

Anti-Inflammatory Activity of Silver Nanoparticles Prepared

from Ginger Oil—An Invitro Approach

M. Maajida Aafreen1, Roy Anitha2, Rachel Christina Preethi1, S. Rajeshkumar2, T. Lakshmi2

1
Graduate Student, 2Associate Professor, Dept of Pharmacology, Saveetha Dental College, Saveetha
Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India

ABSTRACT
Background: Ginger(zingiber officinale) is a widely used spice in cooking and is a medical herb in
traditional herbal medicine. Ginger is herb which is widely used for treating inflammatory conditions and
their associated pain. The utilisation of various plant products for the synthesis of metallic nanoparticles is
called green nanotechnology. It is safe and does not utilise any harmful chemical protocols.
Aim: To evaluate the antiinflammatory potential of ginger oil mediated silver nanoparticle.
Materials and Method: The Silver nanoparticles were synthesised using ginger oil and was confirmed
by UV- visible spectroscopy. The synthesised silver nanoparticles were evaluated for its antiinflammatory
activity by studying the inhibitory effect on albumin denaturation assay.
Result: The present study showed the production of silver nanoparticles at 460nm and was with very good
anti inflammatory activity.
Conclusion: Biosynthesis of nanoparticles using ginger oil was eco friendly, reliable and suitable. So may
be used for large scale production. It was easy to handle and rapid.

Keywords: nanoparticles, nanotechnology, zingiber officinale, ginger

oil

Introduction accordance with their transport and properties(3). As

specific surface area of nanoparticles are increased, their
Nanotechnology is likely to prominently manipulate
biological effectiveness are also increased with increase
science, economy and day to day life in this twenty first
in surface area(4). The unique feature of nanoparticles
century and their potential effects are used widespread
may play a crucial role in biomedicine, energy science,
in both in vivo and in vitro biomedical applications(1).
optics and other health care sector(1). Although chemical
Nanotechnology is mainly concerned with the synthesis
and physical methods may successfully produce pure,
of nanoparticles of variables size, shape, chemical
well defined nanoparticles, these methods are quite
compositions and controlled dispersing for their
expensive and potentially dangerous to the
potential use for human benefits(2). Nano sized particles
environment(2).
are basically small objects that act as a whole unit
in Nanosilver has many important applications. It is
used as anti microbial agent; it is applied in textiles,
home water, purification systems, medical devices,
cosmetics, electronics and household appliances (5,6,7).
Corresponding Author: Silver has been recognised as having an inhibitory
Dr. Anitha Roy effect towards many bacterial strains and
Associate Professor, Department of Pharmacology microorganisms commonly present in medicinal and
Saveetha Dental College, industrial processes. The most widely used and known
Saveetha Institute of Medical and Technical Sciences applications of silver and silver nanoparticles are in the
162, Poonamallee High Road, medical industry. These include topical ointments and
Chennai-600077, Tamil Nadu creams containing silver to prevent infections of burns
Email: [email protected] and open wounds(8). Besides their anti microbial
features, silver nanoparticles exhibit
146 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 146

strong optical features making the nanoparticles suitable Inhibition of albumin denaturation assay: 2ml of 1%
for biological sensing and imaging. Silver nanoparticles bovine albumin fraction was mixed with 400 mL of plant
are also used as catalyst in several chemical reactions.[9 ] extract in different concentration(50-150 mL) and the
pH of reaction mixture was adjusted to 6.8 using in 1N
Nanobiotecnology is a promising field especially HCl. The reaction was incubated at room temperature
for biodiversity rich countrified like India. Biological for 20 minutes and then heated at 55 degrees for 20
diversity can thus be used as a major resource for minutes in a water bath. The mixture was cooled to
biotechnological products and processes, which may be room temperature and the absorbance value was
suitable for large scale synthesis. In recent years, plant recorded at
mediated biological synthesis of nanoparticles is gaining 600nm. An equal amount of plant extract was replaced
importance due to its simplicity and eco friendliness. with DMSO for control. Diclofenac sodium in different
Ginger, the rhizome of Zingiber officinalis Roscoe, is concentrations was used as standard. The experiment
one of the most widely used spices and a traditional was carried out in triplicate to avoid manual error.
remedy in Indian, Chinese, and oriental medicine against
pain, inflammation and gastrointestinal disorders(10). % inhibition was calculated using the following
Ginger is used to treat many inflammatory formula:
conditions and Control O.D. - Sample O.D.
associated pain(11). The essential oil of ginger has % inhibition= × 100
Control O.D.
been
found to possess antibacterial, antiviral and
antifungal
properties. In modern usage, particular attention Result and Discussion
has focused on cyclooxygenase-inhibiting effects of
gingerols, phenolic compounds that are responsible for Medicinal plants are the major source of therapeutic
gingers pungent taste, and their potential use in treating agents to cure human diseases. They are widely used
inflammatory disorders such as arthritis( 12). In this study, in traditional medicine to cure different diseases due
ginger oil mediated silver nanoparticles were prepared to their worldwide availability and fewer side effects.
and further evaluated for its anti-inflammatory activity. The herbal medicines occupy the distinct position right
from the primitive period to present day.. India has a
Materials and Method wealth of medicinal plants and most of which have
been traditionally used in Ayruveda, Unani systems of
Preparation of ginger oil: 1 milli molar of silver nitrate medicine, and by tribal healers for generations.
solution was prepare by dissolving it in double distilled
water. 90 mL of this was mixed with 10 mL of the In medicines, silver and silver nanoparticles have
ginger oil suspension. The solution was kept in many applications including skin ointments and creams
magnetic stirrer/orbital shaker for the formation of containing silver to prevent infection of burns and open
nanoparticles synthesis for 24 hours. The colour change
wounds. Ginger is widely used as spice in cooking and
was observed visually and photographs were taken. as a medicinal herb in traditional herbal medicine(13).
The oil of ginger is a mixture of constituents, consisting
Preparation of nanoparticles: The nanoparticle
solution was centrifuged using Lark refrigerator of monoterpenes and sesquiterpenes. Alcohols and
centrifuge at 8000 rpm for 10 minutes and the pellets aldehydes are also present .
(14)

were collected and washed with distilled water. The

In the last decade, biosynthesis of nanoparticles has
final purified pellets were collected and dried at 60
received increasing attention due to a growing need to
degree Celsius for 2 hours. The powder was finally
develop environment friendly technologies in material
stored in air tight Ependorff tube.
synthesis(15). Nanotechnology is becoming increasingly
UV–Vis analysis of Ginger oil mediated silver important in the food and health sectors(16). Biosynthesis
nanoparticles: The synthesized ginger oil mediated of AgNPs using plant sources offers several advantages
silver nanoparticles was initially confirmed by UV such as cost-effectiveness, eco-friendliness, and the
visible spectroscopy. 3 ml of the solution was taken elimination of high pressure, energy, temperature,
in a cuvette and scanned in double beam UV visible and toxic chemicals necessary in the traditional
Spectrophotometer from 300nm to 700nm wavelength. synthesis methods. Among the various inorganic metal
The results were recorded for the graphical analysis. nanoparticles, AgNPs have received substantial attention
as preservatives, effective antimicrobial and anticancer Antiinflammatory activity: The anti-inflammatory
agents, and biomedical sensors and detectors that exhibit activity of the ginger extract was measured by the
low toxicity for in vitro and in vivo applications(17,18). inhibition of albumin denaturation assay. Inflammation
is the reaction of living tissues to stimuli evoked by
inflammatory agents such as physical injuries, heat,
microbial infections, and noxious chemical irritations.
The response of cells toward inflammation will lead
to certain pathological manifestations characterized by
redness, heat, swelling, and pain with even impaired
physiological functions. Inflammation has been
implicated in the pathogenesis of many diseases
including arthritis, stroke, and cancer (19).Protein
denaturation has been well correlated with the
occurrence of the inflammatory response and leads
Figure 1: Ginger oil extraction (right) and formation various inflammatory diseases including arthritis(20). The
of silver nanoparticles which is identified by the ability of the material to inhibit the denaturation of
change of colour(left) proteins signifies the potential for antiinflammatory
It is well known that silver nanoparticles exhibit activity. The synthesised nanoparticles showed
maximum anti inflammatory activity with 90% of
yellowish- brown colour in aqueous solution due
inhibition at a concentration of
to excitation of surface plasmon vibrations in silver
60. The extract showed a greater % of inhibition
nanoparticles. Reduction of the silver ion to silver
when
nanoparticles during the exposure of the plant extract
compared to the standard diclofenac used in the study.
could be followed by colour change. The reduction
process from silver nitrate to silver ions was observed by
direct visual observation of the solution. The conversion
of pale yellow to dark brown clearly indicated the silver
nano particle production.

UV spectroscopy:

Figure 3: silver nanoparticles of ginger extract in

various concentration for anti inflammatory activity

Figure 2: UV spectroscopy from the extract which

shows the production of silver nanoparticles after
various periods of time

The uv- visible analysis of the silver nanoparticles

were analysed in the absorbence range of 340nm to Figure 4: anti inflammatory activity of silver
540nm. The peak was found to be maximum at 450nm. nanoparticles
Reduction of aqueous metal ions with the ginger oil
indicates the formation and synthesis of the silver BAS (Bovine Serum albumin) was used as a reagent
nanoparticles. for the assay. Bovine serum albumin (BAS) makes up
approximately 60% to all proteins in animal serum.
It
is commonly used in cell cultures, particularly when synthesis of silver nanoparticles using leaves
protein supplementation is necessary and the components of
of serum are unwanted. BAS undergoes denaturation
upon heating and starts expressing antigens associated
with type III hypersensitivity reaction which are related
to disease such rheumatoid arthritis, glomerulonephritis,
serum sickness and systemic lupus erythematosus.

The most commonly used drugs for inflammation

include ibuprofen and diclofenac sodium which belong to
NSAID group of drugs. Though these drugs have shown
good prognosis, they are routinely associated with adverse
effects in the gastro intestinal tract leading to the
formation of gastric ulcer and may also cause
cardiovascular problems as well. Ginger oil can be used
as a natural home remedy as it is readily available and is
economic. According to the research silver particles
produced from ginger oil showed good antiinflammatory
activity and thus can be considered as a potential
candidate as an antiinflammatory agent. Thus reducing
the risk of gastric ulcers and many other health problems.

Conclusion
The silver nanoparticles were synthesised from
the plant Zingiber officinale Roscoe. The study proved
that sliver nanoparticles produced from ginger oil had
potent anti inflammatory property. The present study
emphasises the use of plants for the medicinal purposes.
Further investigations are required for the development
of new classes of analgesics and anti- inflammatory
drugs from ginger oil mediated silver nanoparticles.

Acknowledgement
The authors thank Synthite Industries, Kerala for
providing the ginger oil to carry out this research
project.

Conflict of Interest: Nil

Ethical Clearance: Not required as it is an in vitro

study.

Source of Funding: Self

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DOI Number: 10.5958/0976-5506.2019.01553.5

Comparative Evaluation of Maximum Bite Force and Facial

Morphology—A Cross Sectional Study

Shweta Tiwari1, Arathi Rao2, Ramya Shenoy3, Suprabha BS4

Ex.Post Graduate Student, 2Professor, Paedodontics & Preventive Dentistry, 3Associate Professor,
1

Paedodontics & Preventive Dentistry, 4Professor & Head, Public Health Dentistry, Manipal College of
Dental Sciences, Mangalore, A Constituent Institution of Manipal Academy of Higher Education,
Manipal

ABSTRACT
Purpose: There seems to exist an interaction between craniofacial morphology and bite force. The purpose
of the present study was therefore to compare the maximum bite force with various face forms and facial
measurements.
Method: A total of 212 samples were included in the study. Bite force was recorded using Flexiforce
Sensors. Facial measurements included facial form, height and other measurements. Student t test, ANOVA
test and Post hoc turkey test was applied.
Results: The maximum bite force value showed significant increase, with increasing age. A statistically
significant negative correlation was found between the maximum bite force to the ratio between lower
anterior face height to total anterior face height. Maximum bite force value was recorded for the square face
form and the lowest maximum for the tapering face form.
Conclusion: Maximum bite force has significantly positive relationship with transverse facial dimensions,
Reduced lower anterior facial height and gonial angle was related to maximum bite force and was
significantly higher than subjects with long face.

Keywords: Bite force, facial form, facial

measurements

Introduction strength of the masticatory muscles and its influence on

the form of the face.5 It is concluded that bite force is
Understanding masticatory muscle activity and
higher in individuals with normal facial height than the
influence of physiological factors on occlusal forces,
long faced individuals.6
determining bite force levels, is the emerging new face
of dentistry.1,2 There exists to be a relation between bite force and
transverse facial dimensions.9 It is seen that square facial
There exists an interaction between craniofacial
form have higher bite force values as compared to the
morphology and bite force. Several researchers have
other facial forms.
studied the relation between facial morphology and the
Although much effort has been made to analyze
interdependencies between bite force and these
variables,
there still remains a need to more fully understand
bite
Corresponding Author: forces in very young children with healthy primary
Arathi Rao and permanent dentition and appreciate the dynamic
Professor, Paedodontics & Preventive Dentistry interplay of these range of influencing variables.13
Manipal College of Dental Sciences, The purpose of this study is therefore to compare the
Manipal Academy of Higher Education maximum bite force with the demographic details like
Light House Hill Road, Mangalore-575001 age and gender and also to study the changes associated
Email: [email protected] with various face forms and facial measurements.
151 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 151

Material and Method To measure the maximum bite force, the calibrated
device was positioned across the arches, corresponding to
Study Design: The present study was of cross-sectional
the maxillary/mandibular first molar or premolar region
analytical type. (Fig 2). Each subject was then instructed to bite in centric
Sample Selection: Considering the study power of 80% occlusion as hard as possible, three times in succession,
and statistical significance of 5% with the pilot resting 2-5 seconds, between each bite. The largest value
was selected as the maximum bite force value.
correlation estimate, a total of 212 samples were
included in the study. 110 male and 102 female students
participated in this study. The age range of the samples
comprised of two groups, 5-6 years and 8-10 years. All
participants and their parents received written
explanation of the research purposes and were informed
before the start of the study.

Inclusion Criteria
1. Parents of children who have given consent
for Fig. 2: Device in between the teeth
the study.
Recording the facial measurements: Standardized
2. Children with healthy teeth present in the
frontal photographs were taken. Face forms were
maxillary/mandibular deciduous first molar or
defined as square, square-tapering, tapering and ovoid.
first premolar region.
For standardization, each subject was seated in a chair,
Exclusion Criteria so that the spine is erect and the head centered over the
vertebral column.
Children with following were excluded from the
study For facial measurement, standardized lateral
photographs were taken. Each subject was photographed
1. Acute symptoms such as pain for any reason in profile with the right side of the face towards the
in
investigator. Before the photo was taken, the following
the oral cavity.
landmarks were identified by palpation, and adhesive
2. Malocclusion. dots were placed on the subject’s face. Landmarks
included, Soft Tissue Nasion, Tragion, Menton,
3. Temporomandibular disorder.
Gnathion, Soft Tissue A Point and Gonion. (Fig3)
4. Any kind of disability

Recording the Bite force: The device used to measure

the bite force consists of adapter board, a Phidget
interface kit 8/8/8 board and a Sensor ( FlexiForce,
Tekscan, Inc, USA). (Fig 1)

Fig. 3: Soft tissue landmarks

Fig 1: The device used to measure the bite force
consists of A) Adapter board, B) Phidget interface
kit 8/8/8 board and C) A Sensor
For photographic analysis, indigenous and with increasing age. This relationship was
tested software was used to correct the magnification statistically
differences among photographs. This software measured significant for both right and left side (p < 0.05).
the distance between the two points, by taking into
Association between gender and maximum bite
account, the magnification occurring between the camera
force in 5-6 years revealed that the maximum bite force
and the subject. value on the right side was significantly higher (p <
Facial Measurements: From the photographs, the 0.05) for males than females. However, this relationship
was not significant on the left side.
following was measured.
The values for ratio and gonial angle were stratified
z Nasion-Menton, for total anterior facial height
according to age and gender. A statistically significant
z Soft tissue Point A-Menton, for lower anterior negative correlation was found between the maximum
facial height bite force to the ratio between lower anterior face
height to total anterior face height. This signifies that
z Angle between lines from Tragion-Gonion and
as the ratio decreases, the bite force is seen to increases
z Gonion-Gnathion, for gonial angle. (Table 1). Thus, in subjects with lesser value of lower
anterior face height, depicting a short face, the value of
mean maximum bite force was significantly higher than
Statistical Analysis subjects presenting with long face.
Data analysis was carried out using SPSS
Table 1: Correlation between maximum bite force
version
16.0. The level of significance was kept at p<0.05. The value to the facial measurements
analysis of the association between maximum bite force Gonial
recorded on the left and right side and the demographic Group Gender Bite force Ratio
angle
details, facial measurements was done using Student t Left maximum -.416* -.025
Male
Age group Age group

test. ANOVA test was used in analyzing the different Right maximum -.605* -.050
(5-6)

facial morphology and their association with the Left maximum -.761* -.199
maximum bite force. Post hoc turkey test was then Female
Right maximum -.749* -.227
applied to get a detailed relationship. Left maximum -.724* -.210
Male
Right maximum -.725* -.211
(8-10)

Results Left maximum -.651* -.163

Female
Right maximum -.628* -.112
The maximum bite force on the left side was found *p value <0.005
to be slightly more than the right side in both the age
groups. Gonial angle and Ratio between the lower On analyzing the face form data, it showed that
anterior facial height to total anterior face height was the highest maximum bite force value was recorded for
more in the 5-6 year age group. The maximum bite the square face form and the lowest maximum for the
force was more in boys in both the groups. The Ratio tapering face form.
between the lower anterior facial height to total ANOVA test was then applied to the data to find the
anterior face height and the gonial angle was also more association between these groups. ANOVA test showed
in boys. Student t test, ANOVA and Post hoc turkey test a statistically significant relationship between the face
was applied to the data. The t’ test revealed that for both forms and the recorded maximum bite force values, for
males and females, the maximum bite force value both right and left side.(Table 2)
showed significant increase,

Table 2: ANOVA test

results
Sum of squares Df Mean Square F Sig.
Between Groups 218606.172 3 72868.724
Left
Within Groups 2315888.672 208 6.545 .000
maximum 11134.080
Total 2534494.844 211
Between Groups 210367.864 3 70122.621
Right
Within Groups 2327078.607 208 6.268 .000
maximum 11187.878
Total 2537446.470 211
Post Hoc Tukey test was then applied to find the detailed relationship. The results of both right and left side
showed that the maximum bite force value was significantly higher for square face form followed by square-
tapering, tapering but not associated with the ovoid face form. (Table 3)

Table 3: Post Hoc Tukey test

Mean 95% Confidence interval

Dependent Face Std.
Face form (J) difference Sig. Lower Upper
variable form (I) Error
(I-J) bound bound
Square-tapering 62.51 2.12 .019 7.57 117.51
Square Tapering 98.81 2.26 .000 40.24 157.38
Left Ovoid 44.82 3.15 .487 -36.76 126.40
maximum Square- Tapering 36.30 1.69 .144 -7.62 80.22
tapering Ovoid -17.69 2.77 .920 -89.49 54.10
Tapering Ovoid -53.99 2.87 .242 -128.55 20.57
Square-tapering 62.43 2.12 .019 7.30 117.57
Square Tapering 96.92 2.26 .000 38.21 155.62
Right Ovoid 44.04 3.15 .504 -37.73 125.83
maximum Square- Tapering 34.48 1.69 .181 -9.54 78.50
tapering Ovoid -18.38 2.77 .911 -90.36 53.58
Tapering Ovoid -52.87 2.88 .261 -127.61 21.87

Discussion normal facial proportions develop considerably more

strength as they mature and this may be the reason for
Age group 5-6 depicts the end of primary dentition
children with square face form and short lower anterior
and 8-10 mixed dentition, since by 11 years of age, most
facial height having higher bite force. 14 Skeletal growth
of the permanent teeth are seen to erupt in the oral
to a considerable extent is influenced by muscular
cavity.
growth and the parts of bones to which muscles are
In the present study, bite force value showed attached develop in conjunction with the muscle.
significant gender variation in lower age group with Ingervall and Helkimo in their study found that higher
15

values being higher in boys. However, this can be bite forces correlated with a smaller cranial base
attributed as a chance finding, since studies done in flexure, a deeper upper face, a smaller anterior and a
the past related to gender association, give a wide larger posterior face height, and a less divergent,
range of conclusions. According to Braun et al, 12 the broader face. Also, Proffit et al found a similar kind
14

gender association becomes significant only during the of relationship between bite force magnitude and vertical
postpubertal period. Girls are seen to be as strong as facial morphology, in 1983.
boys until puberty. The increase in muscle mass
In the present study, no significant relationship
produced by androgenic steroids creates the difference
was found between the bite force value and gonial
in male and female physiques following puberty.
angle measurements. Epker et al 17 has proposed that
Another variable considered in the comparison biomechanical factors can influence both direction and
includes the face form and facial measurements. In the magnitude of growth. In his theoretical formulation,
present study, higher value of bite force was recorded decreased occlusal forces are given an important role in
in children having square face form, and those showing the genesis of the long-face condition. The fact that the
a lesser value of lower anterior face height, depicting a long-face condition can be recognized prior to an age
short face. It appears that, for some reason, the children at which decreased occlusal forces are present strongly
with long-facial pattern stop gaining strength in the suggests that the decreased forces are an effect of the
elevator muscles of the mandible, while children condition, not a cause.
with
Conclusion 6. Proffit WR, Fields HW, Nixon WL. Occlusal
forces in normal and long face adults. J Dent Res
Based on the inferences drawn from the present 1983; 62:566–71.
study, it can be concluded that maximum bite force
value in children is dependent on the age, gender, face 7. Fields HW, Proffit WR, Nixon WL, Phillips C,
form and the various facial measurements. The bite Stanek E. Facial pattern differences in long-faced
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force value tend to increase with age and was
23.
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age groups. Facial photographs measurements were 8. Opdebeeck H, Bell WH. The short face syndrome.
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found that maximum bite force has significantly Prahl-Andersen B. Contribution of jaw muscle
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lower anterior face height as well as gonial angle,
10. Bonakdarchian M, Askari N, Askari M. Effect
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of face form on maximal molar bite force with
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with long face. 54(3):201-4.
Ethical Clearance: Taken from Institutional Ethics 11. Hellsing E, Hagberg C. Changes in maximum
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Source of Funding: Self 12. Braun S, Hnat WP, Freudenthaler JW, Marcotte
MR, Honigle K, Johnson BE. A study of
Conflict of Interest: Nil maximum bite force during growth and
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measurement in children with primary dentition.
1. Bonjardim LR, Gaviao MB, Pereira LJ, Castelo
Int J Paediatr Dent. 2011 Mar;21(2):112-8.
PM. Bite force determination in adolescents with
and without temporomandibular dysfunction. J 14. Proffit WR, Fields HW. Occlusal forces in normal-
Oral Rehabil 2005; 32: 577–83. and long-face children. J Dent Res. 1983; 62:571-4.

2. Shiau YY, Peng CC, Wen SC, Lin LD, Wang JS, 15. Ingervall B, Helkimo E. Masticatory muscle force
Lou KL. The effects of masseter muscle pain on and facial morphology in man. Arch Oral Biol.
biting performance. J Oral Rehabil. 2003; 30:978– 1978; 23:203-6.
84. 16. Throckmorton G, Finn R., Bell W.H.
Biomechanics of Differences in Lower Face
3. Sonnesen L, Bakke M, Solow B. Bite force in
Height. Am J Orthod. 1988; 77:410-20.
preorthodontic children with unilateral crossbite.
Eur J Orthod. 2001; 23: 741–9. 17. Epker BN, Schendel SA, Washburn M. Effects
of Early Surgical Superior Repositioning of the
4. Yawaka Y, Hironaka S, Akiyama A, Matzuduka I,
Maxilla on Subsequent Growth: III. Biomechanical
Takasaki C, Oguchi H. Changes in occlusal Consideration. In: The Effect of Surgical
contact area and average bite pressure during Intervention on Craniofacial Growth, McNamara,
treatment of anterior crossbite in primary J.A., Carlson, D.S., and Ribbens, K., Eds., Ann
dentition. J Clin Pediatr Dent 2003; 28: 75–9. Arbor, MI: Univ. of Michigan Center for Human
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Bite Force and Various Variables in Children 18. English JD, Buschang PH, Throckmorton GS.
Segregated by Angle’s Classification. Int J Clin Does malocclusion affect masticatory
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19. Wenzel A, Henriksen J, Melsen B. Nasal 26. Oueis H, Ono Y, Takagi Y. Prediction of
respiratory resistance and head posture: effect of mandibular growth in Japanese children age 4
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1983; 84: 422–6.
27. Katz CRT, Rosenblatt A, Gondim PPC.
20. Solow B, Skov S, Ovesen J, Norup P W, Nonnutritive sucking habits in Brazilian children:
Wildschiodtz G. Airway dimensions and head effects on deciduous dentition and relationship
posture in obstructive sleep apnoea. Eur J Orthod. with facial morphology. Am J Orthod Dentofacial
1996; 18: 571–9. Orthop, 2004; 126(l):53-7.
21. Solow B, Siersbaek-Nielsen S. Cervical and 28. Lyle KC. Airway compromise and dentofacial
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29. Saitoh I, Hayasaki H, Iwase Y, Nakata M.
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Improvement in jaw motion following treatment
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Nissinen M, Könönen M. Maximal bite force
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DOI Number: 10.5958/0976-5506.2019.01554.7

Comparative Evaluation of Tensile Bond Strength and Shear

Bond Strength of Mineral Trioxide Aggregate with Composite
Resin and Resin Modified Glass Ionomer

Radhakrishnan S1, Arathi Rao2, Ramya Shenoy3, Suprabha BS4

1
Ex. Post Graduate Student, 2Professor, Paedodontics & Preventive Dentistry, 3Associate Professor,
Public Health Dentistry, 4Professor & Head, Paedodontics & Preventive Dentistry, Manipal College of
Dental Sciences, Mangalore, A constituent Institution of Manipal Academy of Higher Education, Manipal

ABSTRACT
Background: In a vital pulp therapy such as direct pulp capping or pulpotomy, MTA is directly placed
over the pulp followed by the restoration with resin modified glass ionomer cement or composite material.
An important factor determining the clinical success of such restorations is the bond between MTA and
restorative material. Therefore, the aim of the present study was to evaluate and compare the bond strength
of MTA with Glass Ionomer and Composite resin interface.
Material and Method: The sample size was calculated as 11 in each group. Tensile and shear bond
strength was measured between MTA- Glass Ionomer and MTA- Composite material. Percentage of bond
failure for each group was obtained. Average and standard deviations were calculated and the data was
analyzed by independent‘t’ test. The level of significance was set at 0.05.
Results: Out of the total 44 samples, 29 samples showed cohesive failures. Maximum numbers of failures,
i.e. 17 were in tensile bond strength group which included 8 in RMGIC group and 9 in Composite resin
group. Of the 12 failures in shear bond strength, 5 were in RMGIC group and 7 in composite resin group.
There was no statistically significant difference between the shear bond strength of RMGIC and Composite
with MTA (p = 0.39) at confidence interval of 95%. No statistically significant difference was observed
between the tensile bond strength of RMGIC and Composite samples with MTA (p = 0.41) at confidence
interval of 95%.
Conclusion: There was no difference in the bond strengths attained between Resin modified Glass
ionomers
and Resin Composites with Mineral trioxide Aggregate

Keywords: Mineral Trioxide Aggregate, Glass Ionomer, Composite Resin, Bond

strength
Introduction agent2. In a vital pulp therapy such as direct pulp
capping or pulpotomy, MTA is directly placed over the
The clinical success of any vital pulp capping
pulp followed by the restoration with resin modified
procedures is directly related to the control of pathogenic
glass ionomer cement or composite material.

MTA has a multifaceted range of applicability in

paediatric dentistry due to its superior biocompatibility
Corresponding Author: and sealing ability and less cytotoxicity than other
Arathi Rao materials currently used for the same purpose1.
Professor, Paedodontics & Preventive Dentistry Composite and RMGIC are the material of choice for
Manipal College of Dental Sciences, restorations in pulp treated teeth, due to its high
Manipal Academy of Higher Education compressive strength, adhesion to dentine,
Light House Hill Road, Mangalore-575001 biocompatibility, good sealing ability and handling
Email: [email protected] characteristics. An important factor determining the
clinical success of such restorations is
157 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 157

an adhesive system that provides durable bonding of samples

these materials to dentin and the pulp therapeutic agent.
3

Previous studies comparing the bond strengths

between MTA and GIC or composites under two
different kind of loading forces have yielded varying
results4.

Therefore, the aim of the present study was to

evaluate and compare the bond strength of MTA with
Glass Ionomer and Composite resin interface. The null
hypothesis was that there is no difference in the bond
strength between both Resin modified glass ionomer and
Composite resin with MTA.

Material and Method

The present study was an experimental in vitro

study conducted after obtaining ethical clearance from
the Institutional Ethics Committee.

Sample size: Sample size was calculated based on

the
formula given below
Z a Zb S
n=
d
S, Standard deviation

d, Difference between the two standard deviations

Zβ, 95% Confidence interval CI=1.96

Zβ, 80% Power= 0.84

Hence, At 95% Confidence interval (CI) and 80% of

Power, referring Standard deviation (SD) as ‘2’ and the
difference between the bond strength between the groups
as 3, the sample size was calculated as 11 in each group.

Materials used for the study were Resin modified

Glass Ionomer (GC Gold Label Light Cured Universal
Restorative, GC Corporation, Tokyo, Japan), Composite
Resin (Filtek Z350 Restorative material, 3M ESPE,
dental products, St Paul, USA ) and Mineral trioxide
aggregate (Angelus, Angelus Industria de Productos
Odontologicos, Londrina, PR, Brasil).

The samples were divided into 2 groups equally for

MTA-GIC and MTA-Composite.

Group I – Shear bond strength measurement group-

22
samples

Group II- Tensile bond strength measurement group- 22

158 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 158
Preparation of Samples

For Tensile Bond strength measurement: Circular

acrylic discs of diameter 1cm and thickness of 1-2mm
with a hook made of stainless steel wire inserted on one
side of the disc. 44 discs were made between which the
specimen for tensile strength were stabilized for testing.

For Shear Bond strength measurement: 22 Acrylic

blocks (4cm x 2cm x 2cm) were made. A cavity (5mm
diameter and 2mm depth) was prepared on one side of
the block, 1cm from the top corner.

Cylindrical plastic molds (5mm x 10mm) were used

to make specimens with bonded surface area of 5mm 2.
The MTA was first filled into the plastic mold followed
by RMGIC or Composite accordingly in each group.

All the materials were manipulated as per

manufacturer’s instructions. The surface of the MTA
was made flat by gently condensing with a flat ended
instrument after filling into the mold and all the excess
was removed. The material was kept to set for 24hours
with a moist cotton pellet placed over its surface before
placement of the other material.

Bond Strength Measurement

Tensile bond strength (TBS): The specimen consisting

of a pair of circular discs with MTA-RMGIC or MTA-
Composite sample were one by one separately loaded
into the Universal testing machine (Instron 3366, Instron
corp, Canton, MA, USA). After loaded specimen were
stabilized, the machine was made to work in tensile
mode at a cross head speed of 0.5mm/min until bonded
area failed. The load applied at failure point and the TBS
value was systematically recorded for each sample. The
TBS was expressed in MPa, as derived from dividing
the imposed force (N) at the time of fracture by the bond
area (mm2).

Shear bond strength (SBS): The samples were loaded

into the acrylic blocks such that the RMGIC or
Composite parts were embedded inside the prepared
cavity in it. The MTA part of the sample projected out of
the block which was subjected to the shear load. The
shear bond strength was measured by shearing the
bonded specimens on an Instron universal testing
machine, using a cross head speed of 0.5 mm/minute.
The acrylic blocks were stabilized on shearing apparatus
and a wedge blade system applied a shear force on the
sample. The readings at failure were recorded
systematically.
The compressive load acting on the bonded area was obtained. Average and standard deviations were
on application of shear and tensile force recorded from calculated and the data was analyzed by independent ‘t’
Instron 3366 was tabulated and the bond strength was test. The level of significance was set at 0.05.
calculated by dividing it by the area of bonded surface.
MPa = Force/Area = Newton/mm2 Results
Area of bonded surface, A = pr2; The bond strength values of the two groups, has
r- radius of the specimen used = 2.5mm. been tabulated with their minimum and maximum
values obtained and the mean values of the same in
A = 19.625mm2
Table No.1.

Statistical Analysis The shear bond strength values obtained has

been represented in a Box plot form, which gives the
All statistical analysis was carried out using distribution of the values of the RMGIC and Composite
SPSS groups. The 50th percentile of the values obtained
20 software. Percentage of bond failure for each overlap at the value 5.50MPa. (Fig No.1)
group

Table 1: Bond strength of RMGIC and Composite with MTA (MPa)

Group MIN (MPa) MAX (MPa) MEAN ± SD (MPa)
SHEAR BOND RMGIC (n = 11) 3.65 12.68 7.24 ± 3.64
STRENGTH COMPOSITE (n = 11) 2.67 10.23 6.06 ± 2.74
TENSILE BOND RMGIC (n = 11) .17 1.73 .656 ± .427
STRENGTH COMPOSITE (n = 11) .23 1.67 .806 ± .425

Fig. 1: Box plot form giving the distribution of Shear bond strength values between the groups

The tensile bond strength values obtained has been represented in a Box plot form, which gives the distribution
of the values of the RMGIC and Composite groups. The 50th percentile values do not overlap. (Fig No.2)
Fig. 2: Box plot form giving the distribution of Tensile bond strength values between the groups

The plot form shows distribution of shear bond strength of RMGIC subgroup towards higher values along
the x axis representing the bond strength values in MPa. Whereas in the plot form for tensile bond strength shows
distribution of vaues of composite subgroup was found to be higher on the x axis representing the bond strength
values in MPa.

Shear Bond strength: There was no statistically significant difference between the shear bond strength of RMGIC
and Composite with MTA (p = 0.39) at confidence interval of 95%. (Table 2)

Table 2: Independent Samples Test Comparing Shear Bond Strength

t-test for Equality of Means
Sig. Mean 95% Confidence Interval of the Difference
(2-tailed) Difference Lower Upper
Equal variances assumed .399 1.18272 -1.68180 4.04725
MPa
Equal variances not assumed .400 1.18272 -1.69596 4.06140

Tensile Bond strength: No statistically significant difference was observed between the tensile bond strength of
RMGIC and Composite samples with MTA (p = 0.41) at confidence interval of 95%. (Table 3). So the Null
Hypothesis was accepted as there was no statistically significant difference between the groups.

Table 3: Independent Samples Test Comparing Tensile Bond Strength

t-test for Equality of Means

Sig. Mean 95% Confidence Interval of the Difference
(2-tailed) Difference Lower Upper
Equal variances assumed .419 -.15013 -.52954 .22927
MPa
Equal variances not assumed .419 -.15013 -.52954 .22927
Type of Failures: Out of the total 44 samples, 29 A shear bond strength of about 17 to 20 MPa is required
samples showed cohesive failures. Maximum numbers to sufficiently resist contraction forces and produce gap-
of failures, i.e. 17 were in tensile bond strength group free restoration margins 10-12.
which included 8 in RMGIC group and 9 in Composite
resin group. Of the 12 failures in shear bond strength, 5 Resin modified Glass ionomer showed better shear
were in RMGIC group and 7 in composite resin group. bond strength and Composite resin showed better tensile
The distributions of failed samples have been tabulated bond strength with MTA but both the results were
in Table 4. statistically not significant.

In the present study none of the groups reached the

Table 4: Types of failures optimal shear bond strength. Since the results showed no
significant difference between the shear and tensile bond
strength values between the MTA -Composite and
Cohesive Adhesive
Material MTA- RMGIC groups, the Null hypothesis was
Measurements Failures Failures
used rejected. This results are contradictory to the results
(Nos.) (Nos.)
obtained by Ajami
RMGIC A et al, in which the shear bond strength between MTA
5 6
(11 nos.)
Shear bond and composite was found to be 12.12 ± 2.31 and
strength group Composite between MTA and RMGIC was 3.24 ± 0.58.
Resin 7 4
(11 nos.) Acid etching using 37% phosphoric acid affects
RMGIC the morphology of MTA surface. Under SEM analysis,
8 3
(11 nos.) it was found that etching resulted in a selective loss of
Tensile bond
strength group Composite matrix from around the crystalline structure and due to
Resin 9 2 loss of matrix, the sealing ability and physical properties
(11 nos.) of MTA was found to be decreased14.

The use of 10% polyacrylic acid for smear layer

Discussion
removal, results in mildly demineralized dentin and then
Mineral trioxide aggregate (MTA) has been a helps in chemical interaction between the carboxylic
versatile revolutionary material in endodontics since groups of RMGIC and calcium of hydroxyapatite
its introduction in the 19905. The hydrophilic nature of crystals from dentin leading to mechanical bonding via
MTA makes it an ideal material for different endodontic hybrid layer formation.
applications in which contact with blood, body fluids,
The shear bond strength values between MTA and
and moisture is inevitable, but it may complicate the
Composite obtained were found to be similar to the
bond between MTA and restorative material6.
values obtained in the study by Savadi Oskoee, which
A strong bond between the pulp therapeutic agent had a mean value of 4.65Mpa15.
and the restorative material provides an optimal
hermetic coronal seal. Shear bond strength estimates the As the difference in the shear and tensile bond
local stress and integrity of the materials that the strengths between MTA and the two restorative
bonding layer can withstand. Increased shear bond materials of choice is statistically insignificant, it can be
strength means better bonding between two interfaces concluded that the both the materials bond well to MTA.
and lesser microleakage4,7. The failure of the bond between two materials
The current literature contains few studies on bond may not always result in interface failure but can occur
strength of MTA with RMGIC and Composite resin. in either of the material used for testing. Rigidity of
GIC was found to bond to MTA, although bond strength the material may have a significant influence on the
values of GIC – MTA was comparatively inferior to that interpretation of bond strength16.
of resin composites – MTA8,9. In the present study failure was largely within the
The bond strength between the materials is one of material rather than at the interface. In a study by
the Shenoy et al7 80% of the samples showed cohesive
most critical factors for quality dental filling treatment. failures
within MTA8. The reason for cohesive failure with MTA on dentin of primary and permanent teeth: an
may be due to its porous nature which may be a matter in vitro study. J Indian Soc Pedod Prev Dent.
of concern7. 2009;27(1):33–38.
4. Wang L, Sakai VT, Kawai ES, Buzalaf MA, Atta
Conclusion
MT. Effect of adhesive systems associated with
The choice of restorative material following a pulp resin-modified glass ionomer cements. J Oral
therapy gains as much importance as the pulp Rehabil. 2006;33(2):110-116.
therapeutic agents. With advent of adhesive materials 5. Lee SJ, Monsef M, Torabinejad M. Sealing ability
the scope of pulp therapy has improved significantly. of a mineral trioxide aggregate for repair of lateral
The knowledge about the bonding mechanisms and the
root perforations. J Endod. 1993;19(11):541–544.
bond strengths of the restorative materials will help a
clinician in better treatment planning. 6. Al-Hezaimi K, Al-Shalan TA, Naghshbandi J,
Oglesby S, Simon JHS, Rotstein I. Antibacterial
The conclusions of the study are- effect of two mineral trioxide aggregate (MTA)
z There was no difference in the bond strengths preparations against Enterococcus faecalis
attained between Resin modified Glass ionomers and Streptococcus sanguis in vitro. J Endod.
and Resin Composites with Mineral trioxide 2006;32(11):1053–1056.
Aggregate (MTA)
7. Shenoy V, Margasahayam S, Gulati S.
z Both the materials can be used as a restoration of Comparison of shear bond strength of resin-
choice following a pulp therapy with MTA after it modified glass ionomer to conditioned and
has reached its initial final set. unconditioned mineral trioxide aggregate surface:
An in vitro study. J Conserv Dent.
z It can be a predictable choice to use RMGIC
directly over MTA followed by a composite 2014;17(5):440-443.
restoration (Sandwich Restoration) or a full 8. Yesilyurt C, Yildirim T, Taşdemir T, Kusgoz
coverage restoration (Stainless steel crown). A. Shear Bond Strength of Conventional Glass
Ionomer Cements Bound to Mineral Trioxide
Ethical Clearance: Taken from Institutional Ethics
Aggregate. J Endod. 2009;35(10):1381–1383.
Committee, Manipal College of Dental Sciences,
Mangalore 9. Al-Sarheed MA. Evaluation of shear bond
strength and SEM observation of all-in-one self-
Source of Funding: Self
etching primer used for bonding of fissure
Conflict of Interest: Nil sealants. J Contemp Dent Pract. 2006;7(2):9–16.
10. Atabek D, Sillelioğlu H, Olmez A. Bond
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treatment strategies in vital pulp therapy. J Endod.
Dent. 2012;38(9):1288–1292.
2000;28(2):77-92. 11. Bodanezi A, Carvalho N, Silva D, Bernardineli
2. Modena KCDS, Casas-Apayco LC, Atta MT, N, Bramante CM, Garcia RB, et al. Immediate
Costa CADS, Hebling J, Sipert CR, et al. and delayed solubility of mineral trioxide
Cytotoxicity and biocompatibility of direct and aggregate and Portland cement. J Appl Oral
indirect pulp capping materials. J Appl Oral Sci.
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2009;17(6):544–554.
12. Kayahan MB, Nekoofar MH, Kazandağ M,
3. Yaseen SM, Subba Reddy V V. Comparative Canpolat C, Malkondu O, Kaptan F, et al. Effect
evaluation of shear bond strength of two self- of acid-etching procedure on selected physical
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generation) Endod J. 2009;42(11):1004–1014.
13. Ajami A, Navimipour E, Oskoee S, Kahnamoui 15. Oskoee SS, Bahari M, Kimyai S, Motahhari P,
A, Lotfi M, Daneshpooy M. Comparison of shear Eghbal MJ, Asgary S. Shear Bond Strength of
bond strength of resin-modified glass ionomer Calcium Enriched Mixture Cement and Mineral
and composite resin to three pulp capping Trioxide Aggregate to Composite Resin with Two
agents. J Dent Res Dent Clin Dent Prospects. Different Adhesive Systems. J Dent (Tehran).
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14. Mauro S J, Sundfeld R H, Bedran-Russo A K, 16. Oztürk B, Malkoç S, Koyutürk AE, Catalbas
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DOI Number: 10.5958/0976-5506.2019.01555.9

A Study to Assess the Effectiveness of Planned Teaching

Programme on Knowledge Regarding Prevention of Abuse
among the Children of 11–14 Years of Age at Selected Schools
of Sangli, Miraj, Kupwad Corporation Area

Bhavana Cristopher Samson1, Manisha Sunil Kulkarni2

1
Final Year M.Sc. Nursing. (Student), 2Clinical Instructor, Bharati Vidyapeeth (Deemed to be
University), College of Nursing, Sangli, Maharashtra, India

ABSTRACT
Introduction: Child abuse has serious and psychosocial consequences that adversely affect on the general
well being of kid. In line with World Health Organization agency “Child abuse or mistreatment represent
all sort of physical and emotional maltreatment, sexual offense, neglect or negligent treatment or industrial
or alternative exploration ensuing in actual or potential damage to the kid health,survival,development or
dignity within the context of a relation of responsibility, trust or power.
Aims: 1) To assess the knowledge regarding prevention of abuse. 2) To evaluate the effectiveness of
planned
teaching programme on knowledge regarding prevention of abuse.
Methodology: One group pre-test post-test Pre- Experimental, study was conducted at Sangli, Miraj and
Kupwad Corporation area, quantitative research approach was adopted for this study. The study comprised
of 100 samples. Non-probability convenient sampling technique used for selection of samples. Data was
analyzed using descriptive and inferential statistics. Theoretical framework in study was based on general
systems theory as postulated by Von Bertalanffy (1998).Proposal of tool was presented in front of ethical
committee for permission.
Result and Conclusion: Among the 100 children total mean of Pre-test was 12.91 and mean of post-test
was 19.33 with P value of 0.000 which is significantly high. This shows that the knowledge score of pre-
test was less than post-test knowledge score. Thus null hypothesis is rejected. There is significant change
in knowledge in the post-test. The result of this study proved that the planned teaching programme was
effective. It was concluded from the statistical test that planned teaching programme on prevention of abuse
was effective among children. Analysis of the data showed that there was significant difference between
pre- test and post-test knowledge score. Among the children administration of structure teaching course
have a major impact on awareness score.

Keywords: Assess, Effectiveness, Planned teaching, Knowledge, Child abuse

Introduction
The rate of victimization of kids is 12.3 per 1,000
kids. Kids below 3 years are the foremost probably to
Corresponding Author: experience abuse. They are exploited at a rate of 16.4
Mrs. Manisha Sunil Kulkarni per
Clinical Instructor 1,000.79 share. Kids are killed younger than 4 years.
Bharati Vidyapeeth (Deemed to be University), The statistics are taken from the administration for kids
College Of Nursing, Sangli-416414, Maharashtra, India and Families of the, US Department of Health And
Phone: +91 8483984508. Human services, “Kid mistreatment Report.” There are
Email: [email protected] nearly 3 million reports of kid abuse created annually.
There have been 906,000 maltreatment convictions. The
rate of child
164 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 164

abuse is calculable to the 3 times larger than is children with the sample size of 100.Ethical committee
reported.1 approved the Research proposal. For assessing the
Due to ill-treatment; most of the kids wants to get into a knowledge and effect of planned teaching programme,
wrong manner. Therefore it affects the health of the new on knowledge regarding hindrance of abuse among the
generations. So as to promote the younger generations, children of 11-14 years of age, Quantitative research
this insisted researcher to carry out analysis upon this. approach was adopted for this study. Non-probability
Legal issues are 2.5 million; the numbers of issues are convenient sampling technique used for selection of
informed annually and are increasing continuously of samples. Pilot study and final study were conducted after
kid’s maltreatment and ignorance. Within which 35% approval of the ethical committee.
involves bodily maltreatment, 50% involves sex offence
and 50% involves ignorance. Studies shows those 1 in 4 The prior permission from concerned authority
women and 1 in 8 boys are sexually abused before they was taken and informed written consent from each
are 18 years of age.1 participant parent was taken before conducting the
study. Pre-test was taken by using structured
In India Abused kids are 25% more likely to
questionnaire for
experience adolescent pregnancy. 14, 4 % of all men
15 minutes. Planned teaching programme was given
and 36.7 % of all girls in jail within the US are abused
immediately after pre-test for 45 minutes and after the
as kids. Sexually abused kids are a pair of 2.5 times
seven days, post-test was conducted. The data analyzed
additional probably to develop substance abuse and
3.8 times additional probably develop drug addictions. Based on the objectives of the study, using descriptive
Abused teens are 3 times less probably to practices and inferential statistics. Frequency percentage, Mean,
sexual activity, putting them at bigger risk for STDs.It SD calculated to get the pre-test and post-test knowledge
is known that one third of abused and neglected kids can score. Paired ‘t ‘test applied to check the effectiveness of
eventually put-upon their own kids, and nearly two third Planned teaching programme between the pre-test and
of the individuals in treatment for habit reportable being post-test knowledge score mean. Paired‘t’-test used to
abused as kids.2 compare Pre and Post – test knowledge score.

As per the annual publication of the National

Results/Findings
Crime record Bureau (NCRB), Union Ministry of Home
affairs, throughout 2003,374 children within the age The Data Analyses, which was collected from 100
group of 10-18 were abducted for illicit intercourse samples regarding prevention of abuse among children
and 57 for being forced into prostitution. And 2,949 of 11- 14 years of age. Section- I, Table no. 1 shows
children raped that year, a figure that registered 21 % frequency and percentage distribution of selected
raise in 2004. Abused children are 25 % a lot of possible demographic variables,in that 50 % sample were male
to experience adolescent pregnancy.14.4 % of all men and 50 % were female, 53 % sample were belongs to
and 36 .7 % of all women in jail at intervals the United Nuclear type of family and 47 % were belongs to joint
States are abused as youngsters. Youngsters who are
family. As data given in the table shows 64 % of father
sexually abused are a pair of 5 times extra most likely to
are doing job, and 36 % were doing business. Maximum
practices sexual activity, putting them at larger risks for
samples 56 % mothers were Housewife, and 24 %
STDs, it had been acknowledged that one third of
were doing business, 20 % were doing jobs. Maximum
abused and neglected children will eventually used their
samples mothers that is 60 % were taking care at home,
own children, and nearly two third of the people in
and 40 % others were taking care of children,91 %
treatment for habit reportable being abused as children.3
samples belongs to Urban area and 9 % were belongs
to Rural area. Maximum that is 62 % of samples were
Materials and Method
not having any information about child abuse prevention
One group pre-test–post-test Pre-experimental and 38 % sample were having information about child
design was used for the study. The study is quantitative abuse prevention. 92 % samples were given positive
study. The study was carried out in schools of Sangli, response for conducting workshop on the topic and 8 %
Miraj, and Kupwad corporation area among school were not willing to conduct the workshop.
Section–II
Table 1: Frequency and Percentage Distribution of Pre-Test and Post-Test Knowledge
Score N= 100
PRE Test POST Test
Knowledge Grading
Frequency Percentage Frequency Percentage
Poor 0-6 20 20.00 0 0.00
Average 7-12 31 31.00 10 10.00 %
Good 13-18 40 40.00 20 20.00 %
Excellent 19-25 9 9.00 70 70.00 %

Section –II, Table no1.frequency and percentage distribution of pre-test and post-test knowledge score, at the
time of pre test, 20% of subjects had poor knowledge, 31% had average knowledge, 40% in good knowledge
category and remaining 9% subjects were having excellent knowledge. At the time of post test, 10% of subjects had
average knowledge, 20% in good knowledge category, 70% subjects were having excellent knowledge and no one
in the poor knowledge category.

Section III
Table 2: Comparison of the Pre and Post Test Knowledge Score (Paired T
Test) N = 100
Group Frequency Mean S.D. t value P value
PRE TEST 100 12.91 4.81
16.30 0.000
POST TEST 100 19.33 3.20
Section III table no. 2 comparison of the pre and similar to several previous studies. In contrast to our
post test knowledge score by using paired t test. The pre findings several studies showed that all the students were
test average score was 12.91 with standard deviation having inadequate knowledge and many misconceptions
of 4.81. The post test average score was 19.33 with regarding prevention of abuse among children of 11 – 14
standard deviation of 3.20. The test statistics value of years of age were present. Most of the previous study
the paired’ test was 16.30 with p value 0.000. Shows did not provide any planned teaching program. In
that calculated value is more than tab value there was present study the planned teaching program was given
significant difference in the average knowledge score, at in order to provide appropriate knowledge regarding
significance level of 5%. prevention of abuse among the children and clear the
misconception and encourage the student to take
appropriate action for prevention of abuse activity in
early stage. At the time of pre test, 20 % of subjects
were having poor knowledge,
31 % were having average knowledge, 40 % in good
knowledge category and remaining 9% subjects were
having excellent knowledge. At the time of post test, 10
% of subjects were having average knowledge, 20 % in
good knowledge category, 70 % subjects were having
Figure 1: Comparison of the Pre and Post Test excellent knowledge and in the poor knowledge
Knowledge Score (paired‘t’ test) category there was no one. It shows that there is marked
increase in post-test knowledge. 12.91 is the mean
Discussion value of pre- test knowledge score and post-test
The present study found that the knowledge of knowledge score is
the 19.33, standard deviation score in pre-test phase
participants was not up to the mark. The results are was
4.81 and in the post-test phase it was 3.20.
Calculated’
value 16.30 that is more than tabulated ‘p’ value is 0.000
which is less than tabulated ‘p’ value (0.05). This Conflict of Interest: The authors declare that they have
suggest that there is statistically significant increase in no conflict of interest.
post-test score so planned teaching programme on
prevention of abuse among the school children of 11 Source of Funding: The authors declare that did not
to 14 years of age was effective. The findings of the used any source of funding for conducting the research,
present study with reference to the objectives and expenses is done by self.
hypothesis have been discussed. The finding of the
Ethical Clearance: All procedures performed in studies
study shows that planned teaching programme was
involving participants were in accordance with the
effective.
ethical standards of the institutional and/or national
Similar study was conducted by Ms. Priyanka research committee. Informed consent was obtained
kadam, Mr. Mangesh Vilinikaran Jabade in pune city from all participants parents, included in study.
they assessed the level of knowledge regarding the
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DOI Number: 10.5958/0976-5506.2019.01556.0

Risk Factors Associated with Overweight and Obesity among

Population of Ahmedabad, India

Bhoomi Arora1, Snehal S. Patel2, Banshi Saboo3

Assistant Professor, SAL Institute of Pharmacy, Ahmedababd, Gujarat, India; 2Assistant
1

Professor, Nirma University, Ahmedabad, Gujarat, India; 3Diabetologist, Diabetes Care and
Hormone Clinic, Ahmedabad, Gujarat, India

ABSTRACT
Background: Obesity is one of the leading disorders among developing countries. It is associated with
many chronic disorders such as hypertension, dyslipidemia and vitamin D deficiency. This study aimed at
determining the prevalence of overweight and obesity and its associated risk factors among 12-55 years old
participants of Ahmedabad.
Method: This was a cross-sectional study carried out among 2,412 participants of 12-55 years of age
of Ahmedabad, Gujarat, India. Blood pressure was measured and fasting venous plasma was drawn for
determination of lipid profile, vitamin D level, insulin level and C-reactive protein level.
Results: The prevalence of overweight among 12-17, 18-35 and 36-55 years old participants was 16.23%,
18.51% and 26.22% respectively, whereas obesity prevalence among same age groups was 5.45%, 5.15%
and
5.39% respectively. The risk of pre-hypertension, hypertension, hypercholesterolemia,
hypertriglyceridemia, low HDL-C level, dyslipidemia, vitamin D deficiency, hyperinsulinemia and elevated
C-reactive protein was noted to be significantly higher among overweight and obese respondents than
healthy weight respondents.
Conclusion: The results of this study explains that public health programmes are needed to increase
awareness on risks associated with overweight and obesity such as hypertension, lipid abnormalities,
vitamin D deficiency and elevated C-reactive protein in order to reduce the burden of overweight and
obesity as well as obesity associated chronic diseases.

Keywords: Overweight, obesity, risk factors, lipid profile, vitamin D, C-reactive protein,
insulin
Introduction than one in two adults and nearly one in six children
are overweight or obese in OECD countries with the
Obesity is defined as excess body weight for
highest in the United States, Mexico, New Zealand and
height, which is also associated with excess adiposity
Hungary. If policies for prevention of this preventable
or body fatness. It is a complex, multifactorial, and
disease are not made then by 2030 an estimated 38%
largely preventable disease [1]. Overweight and obesity
of the world’s adult population will be overweight and
has become a public health problem for all strata of the
another 20% will be obese [2].
society worldwide. WHO (2016) has reported
worldwide prevalence of obesity has increased thrice The prevalence of obesity was more than doubled in
from 1975 to 2016. According to obesity update children and tripled in adults of India between 1980 and
(2017), more 2015 reported in the Global Burden of Disease Study [3].
According to Indian Council of Medical Research-India
Diabetes (ICMR-INDIAB) study, the prevalence of
Corresponding Author:
generalized obesity was the lowest (11.8%) in Jharkhand
Bhoomi Arora
(east India) and the highest (31.3%) in Chandigarh
Assistant Professor, SAL Institute of Pharmacy,
(north India) [4]. Overweight and obesity are the fifth
Ahmedabad, India
leading cause of death estimated by WHO [5].
Phone: +91 9824847369
Email: [email protected]
169 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 169

Overweight and obesity are associated with - ATP III (National Cholesterol Education Programme),
many non-communicable, chronic diseases such as 2002 for lipid abnormalities; hypercholesterolemia
hypertension, type-2 diabetes, metabolic syndrome, is defined as total cholesterol more than 200mg/dl,
dyslipidemia, coronary heart disease, stroke, several hypertriglyceridemia as triglycerides more than 150mg/
cancers, disability and increased mortality [6-8]. dl and HDL-C less than 40mg/dl in men and less
than
The aim of this study is to determine the prevalence
50mg/dl in women. Dyslipidemia is considered by the
of overweight and obesity among the subjects of 12
presence of hypercholesterolemia and low HDL-C
–
levels. Vitamin D deficiency is considered if vitamin D
55 years of age of Ahmedabad city. The study is also
level is less than 20 ng/dL. High sensitivity C-reactive
aimed to identify the important factors associated with
protein (hs-CRP) concentration more than 3 mg/L was
overweight and obesity.
considered as having elevated CRP in current study.
According to Melmed et al (2011), hyperinsulinemia
Method

A cross sectional, multi-centric, observational study was defined as fasting insulin level ⩾ 25mIU/L.
was conducted in six different regions of Ahmedabad Results
city. The study included a total of 2,412 participants of
A total of 456 school going children of age
both genders of age between 12 to 55 years old. The
group
subjects were divided into three age groups; 12- 17, 18-
12-17 years old were selected for this study; 16.23%
35 and 36-
were overweight and 5.48% ware obese. Out of 1,010
55 years. Study excluded participants with any previously
participants of 18-35 years old, 5.15% were obese
diagnosed chronic ailments, pregnant or lactating women
18.51% were overweight. The prevalence of overweight
or subjects who are under any drug therapy.
and obesity among 946 subjects of 36-55 years old was
For 12-17 years old children, data was collected 26.22% and 5.39%, respectively.
from schools of Ahmedabad, by conducting health
The prevalence of pre-hypertension was 17.56%
camps at colleges and of six different regions of
and 24.00% among overweight and obese participants,
Ahmedabad. Before conducting any procedure, the
respectively, which was found higher than healthy
participants were well informed about the purpose of the weight subjects of 12 – 17 years old. Similarly, 9.45%
study and were ensured strict non-disclosure of and 8.00% hypertensive subjects were overweight and
information. Signed informed consent form was taken obese in the same age group. Children of 12 – 17 years
from parents/guardians (for 12-17 years) or from old noted to have no lipid abnormalities as well as high
participants (18-55 years). insulin level. Vitamin D deficiency was 70.27% among
overweight and 80.00% among obese children, which
The body weight (kg) and height (m) were measured
was significantly higher compared to healthy weight
and body mass index (BMI) was calculated using
subjects (56.63%). Overweight and obese children found
standard formula: body weight (kg)/height (m ). 2
to have elevated C-reactive protein whilst none of the
Participants were divided into four groups depending on
healthy weight children had elevated C-reactive protein.
their BMI defined by WHO (1999). Overweight and
obesity were considered if BMI is between 25.0 to 29.9 The current study found significantly greater
kg/m2 and BMI greater than or equal to 30.0 Kg/m2, prevalence of pre-hypertension among overweight
respectively. Blood pressure of participants was (33.15%) and obese (40.38%) subjects of 18-35
measured by auscultatory method using standard years than healthy weight (26.53%) subjects, whilst
mercury sphygmomanometer. Participants prior to hypertension prevalence was noted nearly similar
clinical examination were informed not to eat anything among healthy weight (23.64%), overweight (23.52%)
after 10 pm. Next day clinical examination of the and obese (25.00%) subjects. The prevalence of
subjects was carried out by taking their blood samples. hypercholesterolemia (27.27% and 36.53%, respectively
vs 9.54%), hypertriglyceridemia (28.34% and 36.53%,
Pre-hypertension and hypertension was defined respectively vs 12.96%), low HDL-C (47.05% and
by the seventh report of the Joint National Committee 65.38%, respectively vs 21.65%), dyslipidemia
on prevention, detection and treatment of high blood (26.73% and 36.53%, respectively vs 8.83%),
pressure (JNC 7) criteria. According to guideline NCEP vitamin
D deficiency (79.67% and 92.30%, respectively vs reported by Rahmanian et al [24]. The risk of
63.39%), hyperinsulinemia (35.82% and 36.53%, hypertension among overweight and obese subjects was
respectively vs 11.53%) and elevated C-reactive protein higher due to increase in mass, causing an inadequate
(15.50% and 25.00%, respectively vs 9.11%) was noted vasodilatation in the presence of increased blood volume
to be significantly higher among overweight and obese and cardiac output [25].
than healthy weight subjects of 18-35 years old.
It has long been known that obesity attributes to
In present study the prevalence of pre-hypertension lipid metabolism abnormalities which results in
(32.66% and 45.09%, respectively vs 27.24%) and elevation of lipid stores [26]. Though the current study
hypertension (39.51% and 52.94%, respectively vs did not find any lipid abnormalities among children,
28.40%) was significantly higher among overweight and few studies have shown an association between lipid
obese subjects than healthy weight subjects of 36-55 abnormalities and obesity in children [27]. Supporting
years old. Hypercholesterolemia (46.37% and 60.78% the findings of current study, Gayathri et al reported
vs 21.76%), hypertriglyceridemia (59.27% and 64.70% significantly higher value of various lipid parameters
vs 30.23%), low HDL-C (69.75% and 80.39% like total cholesterol, triglycerides and LDL-C in
vs overweight and obese individuals [28]. Inversely, the
35.21%), dyslipidemia (43.54% and 56.86% vs 19.10%), results of Sharma et al and Chadha et al showed HDL-
vitamin D deficiency (79.83% and 92.15% vs 69.43%), C has no significant association with BMI [29, 30].
hyperinsulinemia (50.80% and 56.86% vs 22.92%) and
Vitamin D deficiency is a significant health problem
elevated C-reactive protein (29.43% and 35.29% vs
globally. It helps in the regulation of calcium and
17.94%) were noted to be higher among overweight and
phosphorus homeostasis and hence plays an important
obese subjects than healthy weight subjects of 36 – 55
role in the development and maintenance of good bone
years old.
health [31]. Many studies have supported the current study
finding by reporting higher prevalence of vitamin D
Discussion deficiency among overweight and obese children [32, 33].
Inversely, Bradaran et al noted no significant association
This study reveals increasing prevalence of
between vitamin D level and BMI [34].
overweight with age. Few studies from India on
adolescents reported less prevalence of overweight In line with the finding of current study, Shrinivasan
compared to the result of the present study whilst et al showed temporal relationship between obesity
obesity prevalence was as consistent as the current and hyperinsulinemia and supported the role of obesity
study’s findings [9, 10, 11]. Researchers from Punjab, Jaipur in hyperinsulinemia in three age groups; children,
and Chennai found 10-15% prevalence of overweight, adolescents and young adults [35].
which is noted to be similar to the current findings
whilst they found the prevalence of obesity was as high The current study showed a higher prevalence as
as 5-11% [12, well as higher mean level of C-reactive protein among
13, 14, 15]
. In keeping with the studies of Sen et al and overweight and obese subjects demonstrating the role of
Gupta et al, the current study found consistent results on inflammation in overweight and obesity. Many studies
the prevalence of overweight whereas obesity have supported these findings demonstrating positive
prevalence was lower in current study on adults [16, 17]. association between BMI and C-reactive protein [36, 37, 38].
Furthermore, the findings of few studies on the
prevalence of both, overweight and obesity, documented Conclusion
higher prevalence when compared to the present study
[18, 19, 13]
whilst another study on subjects of 20-40 years The results of this study allow us to affirm that an
old reported consistent findings [20]. increasing prevalence of overweight and obesity due
to unhealthy lifestyle increases the risk of metabolic
Obesity plays a crucial role in the aetiology of syndrome and cardiovascular complications. Thus,
hypertension [21]. The current study reported higher lifestyle modification including understanding of
prevalence of pre-hypertension and hypertension among nutritional behaviour and physical activity decreases the
overweight and obese subjects which was supported risk factors associated with overweight and obesity.
by Dua et al and Yadav et al [22, 23]. Pre-hypertensive
subjects had 1.77% chances of becoming overweight
Acknowledgment mortality of leukemia in adults: a meta-analysis
of prospective cohort studies. Leuk Res. 2012; 36:
We are thankful to Gujarat council of Science and 868–875.
Technology, Gandhinagar and Research Society for the
study of Diabetes in India for proving financial support
in terms of minor research grant.

Ethical Clearance: Taken from Nirma University,

Ahmedabad.

Conflict of Interest: Nil

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DOI Number: 10.5958/0976-5506.2019.01557.2

Fast-Food Marketing and Children’s Fast-Food Consumption:

A Trigger to Childhood Obesity

Binkey Srivastava
Professor, KIET School of Management, KIET Group of Institutions, Ghaziabad

ABSTRACT
Fast-food marketing to children and their parents is considered a stimulus to trigger childhood obesity. The
authors explore the various factors influencing fast food consumption and impact of excessive fast food
consumption. The public health distress with fast-food marketing lies in the anticipated relationship between
fast-food consumption and obesity in both children and adults, along with the nutritional profile of most
fast- food menus.The conceptual framework is designed to understand how does fast-food marketing
influence parents’ behaviors with respect to eating habits of their children in a manner that promote the
development or maintenance of obesity in their children. The random sampling of selected parents of
children aged 2 to 12 years from the community health centre and residential localities of children
within the age group. The convenience sample included 314 parents of children aged 2 to 12 years. At the
end suggested various strategies to reduce the trend of fast food consumption. Fast food intake among
children can be reduced by implementation of policies to regulate the marketing of fast foods in Indian
market. Label of nutrition contents of food might control the quantity of food ordered and choice of low fat
menu among children of educated parents. Further imminent into marketing as an influence on parents’
behavior with respect to eating habits of their children to ensure that food marketing plays a positive role in
children’s health and promotion of healthy eating habits.

Keywords: Obesity, child health, meals, taste perceptions and fast

food.
Introduction As per the various research studies nearly 16%
of children in India are overweight and 31% are in
Childhood obesity has become one of the major risk of falling in this category2. The increased rates of
societal concerns of the 21st century. The problem is obesity have become a public health concern as obesity
global and is steadily affecting many low- and middle- is associated with chronic disease and adverse health
income countries, specifically in urban settings. Over outcomes . The root cause for such epidemic culture
3

the past few years the prevalence of child obesity has is an emerging trend of fast food culture among the
increased at an alarming rate. Globally, in 2010 the younger generation.
number of overweight children under the age of five is Fast food Marketing: Fast food marketing has been
estimated to be over 42 million. Almost 35 million of criticized for targeting children through television
these are living in developing countries (Global Strategy advertisements and for using promotional characters
on Diet, Physical Activity & Health - WHO 2010)1. or favorite cartoon characters and sweepstakes based
on frequent purchase4&5. Beside parents are a major
Earlier in India, childhood obesity was rarely influence on children’s access to food, and parents are
observed but since past few years as malnutrition has also exposed to such marketing . Therefore, the concern
6

attracted the focus of health workers, childhood obesity is to find the ways that marketing adversely influences
children’s weight by means of its effects on parents, such
is increasingly being observed with the changing
as by influencing the types of foods parents buy for their
lifestyle of families with more and more purchasing
children or allow their children to buy? What strategies
power, increasing hours of inactivity due to addiction are needed and appropriate to address such influences?
to television, video games and computer, which have These questions, related to marketing directed at
replaced outdoor games and other social activities. children, have been a focus of this paper.
174 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 174

Factors Influencing Fast food Consumption: Fast content. Hydrogenated oil used in Indian cooking is rich
food restaurants are targeted to maximize the speed, in transfats and have been replaced in many restaurants
efficiency, conformity and sales. The menu is kept by refined vegetable oil. Transfat content in Indian
limited and standardized so as to reduce the waiting time fast food are far higher than western foods10. Transfat
so that the customers eat quickly and leave. This strategy content in bhatura, parantha and puris is 9.5%, 7.8%
reveals the emerging fast food culture in India and its and 7.6%, respectively as compared to 4.2% in regular
impact on children7. French fries. South Indian foods like idli and uthappam
are better as they are good source of carbohydrates and
The fast food chains are further gaining popularity
proteins rather than fat.
through nuclear families as working parents have less
time for meal preparation at home. The great numbers Conceptual Framework and Hypotheses: Favourable
of working parents with school going children are tired attitudes or the belief that behaviour is normative
with exhausting commutes, other household activities in a community may send a subtle message that the
and stress. The children spend most of their time away behaviour is supported and facilitate the likelihood of
from home by attending tuition classes after their school the behaviour. Thus, we hypothesize that fast-food
hours or engaged in recreational activity. Proximity of marketing not only affects consumption levels in the
fast food chains to households could also influence to community of interest (children) but also influences
increased consumption. parents’ attitudes toward fast food and their beliefs about
social norms surrounding fast food consumption. This
Children usually skipping breakfast at home, find
result in more positive fast-food attitudes and the degree
fast food handy in school which results in increased fast
to which parents perceive fast-food consumption as
food consumption and body mass index. It is observed
socially normative are associated with children’s greater
that children from high socio-economic status have
fast-food consumption. Further, parents’ attitudes
more preference for fast foods over traditional foods
and beliefs about fast food strengthen the relationship
irrespective of their better nutritional knowledge8. This
between parents’ easy approachability to fast-food
indicates socio economic status is an important factor
marketing and their children’s fast-food consumption.
related to fast food consumption among children.
Thus the two hypotheses identified are
Indian Fast Foods: India is known for its rich heritage
H1: Parents’ easy approachability to fast-food restaurants
of foods and recipes. Most common north Indian fast
and exposure to fast-food promotion are associated with
foods include chole kulchae, chaat, pakora, chole
their children’s greater frequency of fast-food
bhature, pav bhaji, dhokla, samosa, pani puri aloo
consumption.
tikki and bhel puri. The cooking method of this Indian
fast food decides its calorie and fat content9. Generally H2: Parents’ (a) beliefs about social norms surrounding
most of Indian fast foods are prepared by deep frying in fast food and (b attitudes towards fast food strengthen
fats specifically transfat and saturated fats. Foods that the relationship between parents’ easy approachability
are baked, roasted or cooked in tandoor have lower fat to fast-food restaurants and exposure to fast-food
promotion.

Figure 1: Conceptual Framework for Hypotheses

Method and Measures The analysis supported the relationship (t = 2.66, p =
.009). To demonstrate whether a parent’s perceptions
For the sampling strategy, we randomly selected
of social norms regarding fast food strengthen or
parents of children aged 2 to 12 years from the
account for the relationship between reports of fast-food
community health centre and residential localities using
promotion and fast-food consumption, a second ordinal
a centralized file of chart numbers of children within the
regression analysis was performed. The model included
age group. The convenience sample included 314
the independent variable—fast-food promotions, the
parents of children aged 2 to 12 years. The parents’
putative mediator—social norms and the covariates
education and income with standard demographic
included in the original model. Parents’ perceived social
questions were also assessed. (Table 1)
norms regarding fast food were directly associated
with consumption (χ2 = 8.63, p = .003). However, in
Table 1: Summary of Sample Characteristics this model, parents’ perceived exposure to marketing
N Percentage promotions was no longer related to frequency of fast-
food consumption (χ2 = 2.39, p = .12), which suggests a
Total sample 314 100
mediation effect.
Female 163 52
Younger than age 7 184 59 Exclusively, the results suggest that fast-food
Household Income promotions affect the frequency of children’s fast-food
Less than Rs 3,00,000 p.a. 48 15.3 consumption through influences on parents’ perceptions
about social norms, which provides support for H2a.
Rs. 3,00,000 to Rs. 5,00,000
192 61.1
p.a. The test of the H2b by modelling parents’ attitudes
Rs.5,00,000 to Rs. 8,00,000 or toward fast food as a function of reported exposure
74 23.5
more p.a. to fast-food promotions, after we controlled for the
Parents’ Education covariates discussed in the previous models. We found
12th or less 81 25.8 no association (t = –.86, p = .39), though attitudes
Graduate 142 45.2 did have a direct effect on consumption (χ2 = 10.02,
Post Graduate 91 29.0 p = .002). Thus, parents’ attitudes do not appear to be
Urban Residence 204 65 an intervening variable that explains the relationship
between parents’ reports of fast food promotions and
Overweight 158 50.3
their children’s fast-food consumption. Thus, there is no
At risk of overweight 48 15.2
support for H2b.

Discussions Impact of Excessive Fast Food Consumption:

The major concerns with fast food consumption in
Tests of Hypotheses: To test the hypothesis that developing countries as India include poor hygiene
parents’ higher reported exposure to fast-food during preparation storage and handling leading to
promotions is associated with their children’s more microbiological contamination. Consumption of diet
frequent fast-food consumption (H1; refer Figure1), the high in sugar, saturated fat, salt and calorie content
multiple regression analysis for ordinal outcomes with in children can lead to early development of obesity,
the three-category measure of children’s fast-food hypertension, impaired glucose tolerance and various
consumption as the dependent variable. Further it was other diseases. Fast foods not only have high level of fat
determined whether social norms strengthen the and sugars that unhealthy but have addictive creates a
association between fast- food promotion and children’s vicious cycle making it hard for children to select healthy
fast-food consumption (H2a). To establish the first path food. High content of trans fat in commercially available
of H2a, a multiple linear regression was performed to fast foods predispose children to risk of future heart
test whether parents’ reports of higher exposure to fast- diseases. Energy density of fast food is more than twice
food promotion are associated with more positive social the recommended daily allowance for children. Fast
norms surrounding fast food, after this study controlled food intake leads to higher proportion of calories being
parameters, the child’s age, weight status and for the derived from total and saturated fat11. Moreover, the
parent’s education and income.
micronutrient content (carotene, vitamin A, and vitamin z Chocolates, candies ice-creams and other heavy
C), calcium and magnesium of the fast food is also low. desserts can be replaced by low fat fresh yogurt.
Such diet can contribute to osteoporosis. Diets rich in
z Substitute meat or poultry with baked or boiled
free sugars can lead to increased risk of dental problems.
items, fried with grilled fresh sandwiches.
Strategies to Reduce the Trend of Fast Food: The z Dough used for preparing poori/pakoras should be
enhanced pattern of fast food consumption and thick and avoid using ghee or oil for making the
childhood dietary habits forces to think some strategies dough as this might increase oil absorption.
to curtail it. Strategies could be designed for healthy
food intake by availability of healthy standard foods, z Avoid ordering combo meal or mega meal offer to
information campaigns and surveillance of diets and limit the quantity of the food ordered.
disease burden. Health education and school based z In Indian menu go for tandoori roti as low fat
intervention programs can improve the dietary pattern of option
children. Few schools in India have banned the sale of breads rather than bathure, puri or naan.
junk foods in the school cafeteria. An NGO in India has
z While dining away from home avoid opting for
introduced school mid- day meal programs12 in
dishes with rich creamy layers and lots of spices.
government aided schools, where healthy Indian foods
are offered to children. z Dishes can be shallow fried rather than deep fry to
have lesser the fat content.
Another strategy to enhance the purchase of healthy
foods among children and teens is price reduction on z Avoid motivating children for their
good
healthy snacks as fresh fruits and salad. Nutritional
achievements and academics through chocolate bars.
labeling of low fat label13 too indicates significant
increase in their consumption among teens population. z Last if too fond of such eating give your
In a study it was observed that a 10% increase in the children
cost of fast food meal led to 3% increases in only a single day in a month for this.
consumption of fruits and vegetables.
Conclusions
Further televisions, newspapers and effective school
education campaigns should focus its presentation Parents’ perceptions of more favorable social
on healthy lifestyle and eating among children and norms toward fast food mediate the association between
adolescents. Marketing strategy should be to encourage exposure to fast food promotion and children’s more
children to consume foods with high nutritious value frequent consumption of fast food. This has made
like food grains, pulses, legumes, fruits and vegetables. fast foods an important part of dietary menu for most
In developing country as India where poverty still children, adolescents and even adults. Children are
prevails in major part of country, government has taken lured by convincing marketing strategies and peer
measure to liberalize the international trade to reduce pressure. Consumption of diet high in sugar, saturated
the cost of food grains. However, trade liberalization14 fat, salt and calorie content in childhood can lead to
has led to massive infiltration of Indian market with early development of obesity and cardiovascular risks.
fast food joints. Policy reforms and imposing heavy tax Fast food intake among children can be reduced by
on imported and manufactured readymade food items implementation of policies to regulate the marketing of
might control this intrusion. fast foods in Indian market. Nutritional labeling of food
might restrict the quantity of food ordered and choice
Following measure could be adopted by parents of low fat menu among children of educated parents.
to Additional insight into marketing as an influence on
promote healthy food intake among children: parents’ behavior with respect to feeding their children
z Aerated beverages should be replaced by fresh lime to ensure that food marketing plays a positive role in
juice, coconut water and fresh fruit juices. children’s health and promotion of healthy eating habits.

z Child should be tempted with a plate filled with Overall, the results of this study show that fast-food
plenty of brightly colored vegetables, fruits and marketing influences parents’ behaviour with respect to
sprouts. feeding their children. Thus, for a more comprehensive
understanding of approaches to reduce childhood obesity
and related cardiovascular risk factors, research that 6. Sonya A. Grier, et.al. Fast-Food Marketing and
assesses the influence of marketing on children’s eating Children’s Fast-Food Consumption: Exploring
behaviours and policy debates about food marketing to Parents’ Influences in an Ethnically Diverse
children should consider parents’ marketing exposure. Sample, American Marketing Association2007,
Additional insight into marketing as an influence on Vol. 26 (2) pg 221-235.
parents’ behaviour with respect to feeding their children
will assist researchers, policy makers, and marketers in 7. Vijayapushpam T, Menon KK, Rao R D, Maria
developing mediate to ensure that food marketing plays Antony G. A qualitative assessment of nutrition
a positive role in children’s health. knowledge levels and dietary intake of school
children in Hyderabad. Public Health Nutr.
Ethical Clearance: Taken from nil committee 2003;6:683-8.

Source of Funding: Self 8. Niemeier HM, Raynor HA, Lloyd-Richardson

EE, Rogers ML, Wing RR. Fast food
Conflict of Interest: NIL consumption and breakfast skipping: Predictors of
weight gain from adolescence to adulthood in
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DOI Number: 10.5958/0976-5506.2019.01558.4

Retina Identification System Using Machine Learning and

Multiple Regression Model

D. Nagarajan1, R. Sujatha2, J. Kavikumar3, Udaya Mouni Boppana4, Dhivyapriya4

Professor, Department of Mathematics, Hindustan Institute of Technology & Science, Padur;
1

Associate Professor, Department of Mathematics, SSN College of Engineering, Chennai; 3Professor,

Madya Universiti Tun Hussein Onn Malaysia, 86400 Parit Raja, Malaysia; 4Student, Department of
Computer Science, Hindustan Institute of Technology & Science, Padur

ABSTRACT
In recent year, Macular Degeneration is the leading cause of vision loss. Macular Degeneration is caused by
the deterioration of the central portion of the retina, the inside back layer of the eye that records the images
we see and sends them via the optic nerve from the eye to the brain. The retina’s central portion, known as
the macula, is responsible for focusing central vision in the eye, and it controls our ability to read, drive a car,
recognize faces or colors, and see objects. The aim of our proposed paper is to detect macular degeneration
by using machine learning and regression analysis. This involves segmentation, plotting of histogram, edge
detection and singular value decomposition. The results derived from edge detection are used in regression
analysis.

Keywords: segmentation, edge detection, singular value decomposition, multilinear regression,

multicollinearity
Introduction these types of degeneration is genetic disorder and
ageing. It is necessary for new approaches involving
Eye health assistance of people is an issue of great
machine learning to diagnose and detect these effects in
relevance. In the recent years in Indian societies, it is
time for better health adjunct system. It helps the society.
observed that so many people are facing more
Damage of macula and a little blemish approximately
challenges to protect their eye. Developing countries
close to the midpoint of eye in the retina leads to retina
like India, face more age related diseases among elderly
degeneration and subsequently vision loss. The retina
groups. The most common disease in eye is aged
degeneration progress is quick and might lead to vision
macular degeneration. The primary reasons for this
loss in one eye or both eyes. The general symptom of
disease are aging and genetic disorder. To overcome
retina degeneration is blurred region close to the mid of
these issues, health assistance and monitoring system for
vision.
early detection of aged maculer degeneration through
machine learning prediction algorithm is proposed. This
helps in remote interaction with society. Method Details

Reason for degeneration is eventually demise of cells This paper presents a method for detection of
in retina. Other cause of degeneration is blockage in vein macular degeneration using machine learning and
and diabetic. The degeneration causes blindness, starting multiple regression analysis. Reason for degeneration is
with tunnel vision, peripheral sight loss. The main cause eventually demise of cells in retina. Other cause of
of degeneration is blockage in vein and diabetic. The
degeneration causes blindness, starting with tunnel
vision, peripheral sight
loss. The main cause of these types of degeneration
Corresponding Author: Email: [email protected]
D. Nagarajan
Professor, Department of Mathematics,
Hindustan Institute of Technology & Science,
Padur-603103
is genetic disorder and ageing. It is necessary
for new approaches involving machine
learning to diagnose and detect these effects
in time for better health adjunct system. It
helps the society. Damage of macula and a
little blemish approximately close to the
midpoint of eye in the retina leads to retina
degeneration and subsequently
179 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 179

vision loss. The retina degeneration progress is quick and

might lead to vision loss in one eye or both eyes. The
general symptom of retina degeneration is blurred region
close to the mid of vision.

Machine vision should be a direct method for

getting information of surroundings. the human eyes
location problem has attracted significant interests in the Fig. 1: Normal retina,diseased retina
last decades 1,2,3. Many efforts have been addressed to
seek for eyes. A pupil generally is darker than surround
eyeball, therefore algorithms can be designed to search
Methodology
for gray character4. For more effective, gray balance The methodology involves, machine learning,
or contrast enhancement can be employed. Based
singular value decomposition and multiple linear
on it, precedential knowledge on the facial feature
regression analysis. The images are selected from
arrangement will be helpful to detect several candidates
of eyes 5,6,7. But, the color of pupil must sharply affect the database and processed using MATLAB-R2015a.
the work of algorithms, as well as lighting condition. For Singular value decomposition is used for comparison
solving these problems, an artificial template could be of normal iris and degenerated iris. The results of SVD
involved. So, in 8, the correlation coefficient between the are validated through linear multiple regression analysis.
template and the eye image can be calculated to decide For performing multiple regression analysis, SPSS tool
which eye pair is. In addition, in the interest of reducing is used. Many methods exist to validate the results, but
disturbance of color, Hough Transform is proposed to application of linear multiple regression analysis is a
find the circle shape of the eye irises and eyelids9. As we novel approach to validate the results.
know, the Hough Transform should lead to heavy load
of calculation. Furthermore, NN can be counted on to The RGB image is converted to grey scale image.
solve problem well. Bianchini and Sarti 10 refer to the
eyes possess strong horizontal and vertical edges, the
exploitation of gradient features is particularly suited
to repre sent the image content. Therefore, a neural
autoassociators can be trained to detect eye region by
gradient features. In order to extract gradient features,
Sobel filter is utilized. More recently, Gabor wavelets
techniques 11, where Gabor wavelet-based linear filters
are used for eye corner detection, and non-linear
(Gaussian) filters are used for eye location. Moreover,
the fractal model provides an excellent representation of
the ruggedness of natural surfaces and has served as an
image analysis tool for a variety of applications. Fig. 2: Detection of blood vessels in the normal
retina of the eye
A review of the image, machine learning
techniques, detection, classification to filter the medical
image and to perform disease area segmentation12,13.
The application of various image processing techniques
for automatic detection of glaucoma is presented in 14.
An approach for automatic classification of fundus
images using image and data pre-processing techniques
to improve the performance of machine learning
classifiers 15,16. In 17, application of singular value
decomposition is discussed. Machine learning
techniques, detection, classification to filter the medical
image18,19.
Fig. 3: Detection of blood vessels in the upnormal
Data Base: Retina gallery full sized retina image in fig 1
retina of the eye
normal image and diseased retina.
Histogram plot of the image is in Fig.2 and 3. The vectors of . Any non-square matrix is converted as a
histogram plot reveals the intensity of light distribution square matrix through singular value decomposition in
and peak of macular degeneration black spot. The order to calculate the correlation coefficient. Detection
histogram of normal eye, Fig.2a is not skewed and the is mainly based on the comparison of correlation
shape of the cur ve is leptokurtic, it shows there is no coefficient normal iris and degenerated iris.
drusen in the background of the eye. The histogram of
diseased eye, Fig.3 is positive skewed, and leptokurtic. Diagnostic test indicates the presence of disease
It shows small amount of drusen is distributed in the when the result of the diagnostic test is true positive.
background of the eye. Almost symmetric histograms, The test suggests the disease is absent as well, when
we observe high concentration of pixel around the the outcome is true negative (TN). In the condition of
mean value. From diseased eye, Fig.3 is leptokurtic and no information about the disease, the test result is false
the distribution allow the existence of small drusen as positive (FP). Similarly, if the result of the diagnosis test
outlayers and that do not alter the general uniformity of reveals that the disease is absent for a patient for sure,
the intensity. the test result is false negative (FN).
The original image is converted from RGB to In order to correctly identify as normal iris image
Green Channel. Complement structuring Element and to correctly identify diseased iris, true positive
Morphological operation is done by Median Filter. is used. While, comparison of the images using SVD
Removal of background and image adjustment using and correlation coefficient, a threshold of 80% is set to
intensity of the image is performed. Fig. 4, show classify as True positive and True negative. The values
the segmentation of the retina blood vessels through of TP and TN are taken as independent variables of
morphological operation of normal and diseased eye multiple linear regression analysis. The dependent
respectively. These allow the ophthalmologist to analyze variable is formed through AND logic gate.
the blood supply to the retina through cluster centres.
Multiple regression is a statistical technique that
allows us to predict dependent variable or criterion
variable on the basis of several independent variables or
predictor variables. The general multiple regression is in
the form of, where denote the measure of how strongly
to each predictor variable influences the criterion
variable.
Here, the resulting multiple regression equation is
Y= -0.069+0.7245 x1+0.2875 x2. As x1 increases
Fig. 4: Segmentation of blood vessels
by
The singular value decomposition is closely 72%, the output Y increases and x2 increases by 28%,
associated to the companion theory of diagonalisation of the output increases. Table 1 reveals that the adjusted
symmetric matrices. If A is a real symmetric n x n value is 0.75, thus our model is fit for dependent
matrix there is an orthogonal matrices U and V and a independent variable. The reports on ANOVA, which
diagonal matrix S such that. assess the overall significance of our model from p-
value is less than 0.05, so our model is significant
Here the columns of V are latent vectors for A and for analyzing dependent and independent variable in
diagonal entries of are eigen values of A. Here U is m table 1 and table
x m and V is n x n, so that S is rectangular with the 2. Output from the multiple regression model show that
same dimensions as A. The matrix S can be formatted If the variable x1 is increase then the dependent variable
to be non-negative and in order of decreasing order. The is increase. Variable x2 increase then the dependent is
columns of U and V are called left and right also increase. Further analysis the multiple collinearity
singular to check for all variable. Because from multiple
collinearity we can analysis the nature of the variable.
dependent and independent variable in table 1 and table
2.

Table 1: Model summary and ANOVA

Std. Error
R Adjusted R Square F Sig. F Durbin-
Model R of the df1 df2
Square R Square Change Change Change Watson
Estimate
1
1 .864a .747 .72 .23821 .747 2 97 .000 1.302
43.238
Table 2: Collinearity Diagnosticsa
Dimension Eigenvalue Condition Index Constant Var 1 Var 2
1 2.1 1 0.08 0.08 0.09
2 .54 2 .08 .17 .89
3 .29 2.7 .84 0.75 .02
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1
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2

VIF is 1 means that there is no correlation Informed Consent: Informed consent was obtained
among
from all individual participants included in the study.
the variable. VIF is exceeding 4 warrant further
investigations. VIF is exceeding 10 are sign of serious
multicollinearity problems.

Here, VIF = 0.27. This indicates, that the model

is
not seriously affected by multicollinearity .

Conclusion

From the above results are shows that 72 percentage

fit for detection of disease. The characteristic of the edge
of nerves is perfect for identification of macular.
Remaining portion of the 28 percentage is due to the
problem with some nerve diseases at the time of
checking.

Notes

Compliance with ethical Standards

Conflict of Interest: The authors declare that they have

no conflict of interest.

Ethical Clearance: The article does not contain any

studies with human participants or animal performed by
any of the authors.
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DOI Number: 10.5958/0976-5506.2019.01559.6

Breast Cancer Prediction Using Ensemble Techniques

G. Manikandan1, B. Karthikeyan1, P. Rajendiran2, R. Harish3, T. Prathyusha3, V. Sethu3

1
Senior Assistant Professor, 2Assistant Professor, 3Student, School of Computing, SASTRA
Deemed
University, Thanjavur, India

ABSTRACT
One of the most dangerous types of cancer affecting women across the world happens to be breast cancer.
As per clinical experts, detecting this cancer in its first stage is crucial in saving lives. The variables like
sample code number, clump thickness, uniformity of cell size, uniformity of cell shape etc., are some of the
important risk factors providing information, allowing identification of the recurrence of breast cancer and
cure it in the earliest stages.
The factors responsible are obtained as an output from the data mining models. Existing studies and their
results have produced good accuracies with minimal error rates in prediction. The medical diagnostic
models which are based on data mining techniques can capture delicate designs and dependencies
providing promising results. Promising results can be obtained from medically focussed diagnostic models
which are based on data mining techniques, which have the capability to interpret ethereal structure and
relationships. Single data mining technique may not suffice in providing results which are constant and
competent.
Ensemble learning involves the blending of combination rules with input as several selected and generated
intermediate risk factors to finally obtain simple selection results as output. The aim of this paper is to
analyse the existing standard methodologies and to develop a new ensemble model comprising of
classification techniques which will result in higher precision.

Keywords: Breast Cancer, Prediction, Voting, Stacking,

Boosting.
Introduction sorting and rearrangement, data summary/aggregation,
data calculation, data selection.
According to government statistics, breast cancer is
one of the leading cancers affecting Indian women with Ensemble learning by its name involves the
a rate as high as 25.8 per 100,000 women and mortality inclusion of more than one entity such as models. It
of 12.7 per 100,000 women. [1, 2]The average 5-year is primarily used to meliorate the performance of a
survival rate for women with invasive breast cancer model (classification, prediction, an approximation of a
is function, etc.), reduce the probability of a poor pick or
90%. The average 10-year survival rate is 83%. both. [4, 5] A good model of machine learning on unseen
data should be able to perform well. The ordinary
The information obtained from this data is analysed methods of machine learning, however, learn from the
from a large existing data, which makes it possible training data only one hypothesis. Various methods give
to make the right decision following the important rise to different hypotheses, but cannot justify
information collected. Due to the rigid, complex nature completely on its own. Therefore, many hypothesises
of data processing, it can still be divided into simple are learned and combined to form a good hypothesis in
steps. [3] These steps include data classification, data order to achieve
better results on unseen data. Instead of just one model
Corresponding Author: training and using the combined hypothesis of all the
G. Manikandan individual hypotheses, many models are trained on the
Senior Assistant Professor, data in ensemble learning, as your final hypothesis. The
School of Computing, models which are combined are called base learners.
SASTRA Deemed University, Thanjavur, India [6,7]
Ensemble principally includes Bagging, Boosting,
Email: [email protected] Stacking and voting techniques.
184 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 184

In bagging, various training data subsets are drawn contributes a single vote in its simplest form, based on
from the entire training dataset in a random manner a plurality or majority vote. Summarizing all votes and
with replacement. Ensemble decision for any given selecting the highest aggregate class ensues the final
instance is the predominant chosen class, which is from prediction.
the combination if respective classifiers by mean of
majority vote. Measures such as the usage of a subset Proposed System: We used the method of selection
of training data to train each classifier or using relatively of features and assembly techniques in our proposed
weak classifiers (such as decision stumps) can be used to system. Feature selection process helps in reducing
enhance diversity. The need for additional measures is inputs for processing and analysis, improving the quality
due to significant overlapping of training data sets. of the model and also making the modelling process
more efficient. On omitting the feature selection method,
Boosting creates a classifier ensemble by resampling quality degradation can be observed due to unessential
the data, later combined by majority vote. Classifiers columns resulting in:
with the most informative training data are created via
resampling, resulting in the three weak classifiers. The 1. Noisy or redundant data makes it more difficult to
ordinal classifier involves training with a randomly discover meaningful patterns
chosen subset from the available training data. The most 2. Larger training data set is required by the majority
elucidative subset where only half of the training data of data mining algorithms, where the data set is
are properly classified and the other half are defined in higher dimensions.
misclassified is fed as the training data subset for the
second classifier. The third classifier is trained and The objective of our proposed work is to construct
disagrees with instances. The three classifiers are an ensemble with K nearest neighbour and Naïve Bayes
combined by a majority vote of three ways. algorithms. Here we have given Wisconsin dataset as
an input to the K nearest neighbour algorithm and the
Stacking is to explore the same problem with a
output obtained from this algorithm is given to Naïve
space of different models. The idea is that you can
Bayes algorithm. Then ensemble methods like Bagging,
attack a learning problem with different types of models
Boosting, Stacking and Voting are applied to these
which are capable to learn some part of the problem, but
algorithms. As mentioned in Table 1 we have done this
not the whole space of the problem. So you can build
process with a different number of features.
multiple different learners and you use them to build an
intermediate prediction, one prediction for each learned
Results and Discussion
model. Then you add a new model which learns from
the intermediate predictions the same target. It is said For experimental purpose, we have used Wisconsin
that this final model is stacked on top of the others. So dataset. It has 683 instances and 9 attributes namely
you could improve your overall performance, and you sample code number, clump Thickness, Uniformity of
often end up with a model that’s better than any cell shape, Uniformity of cell size, Marginal adhesion,
intermediate individual model. Singe epithelial cell size, Bare nuclei, Bland chromatin,
Voting is a technique of aggregation used to normal nucleoli, Mitosis. From the Table 1, it can be
combine inferred that voting ensemble method results in higher
multiple classifier decisions. Every single classifier accuracy.

Table 1: Accuracy with different Features

Sl. Accuracy
Techniques
No. All Features 8 Features 7 Features 6 Features 5 Features
1. KNN 95.07 95.08 94.79 94.64 94.64
2. Naive Bayes 94.16 94.34 94.19 93.75 94.19
3. Ada Boosting 95.47 95.46 95.76 95.76 96.05
4. Grad Boosting 96.35 96.49 96.20 96.50 96.49
5. Stacking 96.52 96.66 96.52 96.08 96.37
6. Voting 97.07 97.08 96.49 96.93 96.64
Conclusion 2. Landrum LM, Java J, Mathews CA, Lanneau Jr
GS, Copeland LJ, Armstrong DK, et al.
The proposed scheme can provide promising
Prognostic factors for stage III epithelial ovarian
results in the prediction of breast cancer. Our approach
cancer treated with intraperitoneal chemotherapy:
intromits multiple independent variables and provides a
a Gynecologic Oncology Group study.
practical and useful tool for outcome prediction of breast
GynecolOncol. 2013;
cancer. Here we have used feature selection method and
130(1):12–8.
also some ensemble techniques with Naïve Bayes and K
nearest neighbour algorithms which help in the best 3. Mangone L, Mandato VD, Gandolfi R, Tromellini
prediction of breast cancer by improving the accuracy. We C, Abrate M. The impact of epithelial ovarian
can infer from the output that voting is the best technique. cancer diagnosis on women’s life: a qualitative
Our future research endeavours include the practice of study. Eur J GynaecolOncol. 2014; 35(1):32–8.
medical diagnosis scheme involving proposed machine 4. Nolen BM, Lokshin AE. Screening for ovarian
serving as a foundation for critical dealing with medical cancer: old tools, new lessons.Cancer Biomark.
problems.
5. 2010;
Delen 8(4–5):177–86.
D, Walker G, Kadam A. Predicting
Ethical Clearance: Not required breast
cancer survivability: a comparison of three
Source of Funding: Self data mining methods. Artif Intell Med. 2005;
34(2):113–27.
Conflict of Interest: Nil
6. cancer
Utomo diagnosis
CP, Kardiana
usingA,artificial
Yuliwulandari
neural R.
REFERENCES networks
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1. Chih-Jen Tsenga, Chi-JieLub, Chi-Chang Changc,
Gin-Den Chena, ChalongCheewakriangkrai. 7. Previs RA, Bevis KS, Huh W, Tillmanns T, Perry
Integration of data mining classification L, Moore K, et al. A prognostic nomogram to predict
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Artif Intell Med. 2017; 78: 47–4. chemotherapy. GynecolOncol. 2014; 132(3):531–6.
DOI Number: 10.5958/0976-5506.2019.01560.2

Effects of Pesticides on Lung Function Test in Farmers of

Satara District, Maharashtra, India

Gauri Joshi1, A. G. Joshi2, S. N. Patil2, Ajit Sontakke3

1
Ph.D. Student, 2Professor Department of Physiology, 3Professor & HOD Department of
Biochemistry, Krishna Institute of Medical Sciences, Karad, Maharashtra

ABSTRACT
Introduction: Indiscriminate use of pesticides like organophosphate, organochlorine, carbamate and
pyrethroid poses various health hazards to human nervous, respiratory, endocrine, reproductive and
immune systems.
Objectives: To access extent of derangement in respiratory function of farmers who are exposed to
pesticide
in the Satara District.
Method: 40 pesticide sprayers having age group 25-35 were selected as subjects. 40 age matched healthy
farmers who were not involved in spraying activity were taken as control. Lung function was measured in
morning by using computerized “HELIOS 701” instrument which includes FVC (Forced Vital Capacity),
FEV1 (Forced Expiratory Volume in First second of FVC), FEV1% (FEV1as % of FVC), PEFR (Peak
Expiratory Flow Rate in liters/sec), FEF25-75% (Forced Expiratory Flow Rate during 25to75 % of
expiration), FEF 0.2-1.2 (Forced Expiratory Flow between 0.2-1.2 liters of expiration) and MVV
(Maximum Voluntary Ventilation). After computing mean and SD of both groups comparison was done
by using Unpaired t test to find out level of significance.
Results: Impairment of lung function (Predominantly restrictive type) was found in study groups as
compared to controls.
Conclusions: Exposure to pesticides causes lung function derangement in pesticide sprayers.

Keywords: lung function, pesticide sprayers.

Introduction pesticides to gain higher cultivation has become major

public health problem.[3]Indian agriculture industry is
Pesticides are profusely used to increase
not as mechanized and advanced like other countries
agricultural productivity and to eradicate many vector-
and its more labour intensive. There is no use of
borne diseases.[1]Indiscriminate use of pesticides like
personal protective equipments (PPE) during spraying,
organophosphate, organochloride,carbamate and
poor housekeeping and storage, improper handling of
pyrethroid poses various health hazards to human
pesticides leading to increased health hazards. [4] Hence
nervous, respiratory,endocrine,reproductive and immune
farmers are exposed directly to pesticides.
systems[2]. In modern agricultural practices use of more
Farmers are exposed to pesticide mainly by three
ways. Firstly, through skin or eyes, secondly through
Corresponding Author: mouth and thirdly through lungs (inhalation).Lung is
Gauri Joshi target organ of inhaled toxicants and affected subsequent
Ph.D. Student, Department of Physiology pesticide exposure by inhalation.[5]Long term exposure to
Krishna Institute of Medical Sciences
cholinesterase- inhibiting pesticides those producing
Karad, Maharashtra
vapours, air droplets may cause irritant effects in
Email: [email protected]
respiratory tracks, lungs and lead
187 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 187

to narrowing of airways, damage to the alveolar capillary Materials & Method

membrane and gas diffusion impairments.[6]There are more
In this study, 40 pesticide sprayers having age group
deaths due to pesticide poisoning than infectious diseases
25-35 were selected as subjects. 40 age matched healthy
in the developing world. Pesticide poisoning among
farmers who were not involved in spraying activity were
farmers and occupational workers is alarming.[7]World taken as control group. Both groups were having same
Health Organization (WHO) estimated that approximately socioeconomic status. The study was conducted in
20,000 workers die from exposure of pesticide every year, Satara District during the period from November
majority in the developing countries.[8]Recently on 2017 to Feb
Wednesday, August 15, 2018, The Times Of India, New 2018. Approval from Institutional Ethical Committee
(IEC) was taken prior of starting research. Sprayers
Delhi Indian newspaper reported some pesticides were
were having pesticide exposure for an average of 7-8
banned by Indian Government as their usage is cause for
years. A detail history of both groups was taken by use
cancer. of questions regarding duration of work, smoking habits,
diet and present respiratory symptoms. Prevalence
Farmers in developing countries are under
of respiratory symptoms was recorded by using
impression that pesticides are substitutes for fertilizers
questionnaire which is based on British medical research
and there is need to create awareness at grass root level council.[10]The questions were formulated in such a way
among the farmers.[9]The researchers till date in some to get maximum information about respiratory
parts of India have studied effects of pesticide spraying symptoms of pesticide sprayers over the period of last
on lung functioning of farmers. But they have studied one year. It includes prevalence of upper respiratory
only few parameters of pulmonary function test (PFT). symptoms such as sinusitis, rhinitis, sore throat,
Very less work has been done on PFT of farmers in the common cold and fever. Prevalence of lower respiratory
Satara District. Therefore aim of present study is to symptoms such as dry cough, wet cough, wheeze,
access extent of derangement in respiratory function of heaviness in chest and dyspnoea. Dyspnoea was
assessed by using dyspnoea scale of Medical
farmers who are exposed to pesticide in Satara District.
Research Council.[11] It comes under
six headings as following.

Category Symptoms Dyspnoea grade

0 No any abnormality No
1 Shortness of breath while walking up slight hill or hurrying on the level. Slight
2 Walk slower than people of same age on the level due to breathlessness. Moderate
Moderately
3 To stop while walking at own pace on the level due to breathlessness.
severe
4 Stops for breath after walking about 100 yards or after a few minutes on the level. Severe
5 Too breathless Very severe

The sprayers having smoking habits, past history demonstration of the test. Consequently minimum three
of respiratory or cardiac disease were excluded from readings of each test were taken for every subject and
the study. Institutional Ethical Committee (IAC) the best of three was selected for having reproducibility
approval was taken. Informed written consent from all and validity of the recorded parameters.
the subjects and controls was taken. Anthropometric
measurements like height and weight were recorded for Statistical Methods: SPSS version-20 was used for
each participant. Their lung function tests were done statistical analysis. Mean and standard deviation (SD) of
preferably in the morning.Lung function was measured
each variable was calculated. Unpaired t test was used to
by using a computerized “HELIOS 701” (RMS
Chandigarh, India) instrument.Spirometry was carried find out level of significance. The difference was said to
out as per guidelines of American Thoracic Society.[12] be significant if P< 0.001***, P< 0.01**, P< 0.05* when
Before recording lung functions, subjects were shown a compared to control.
Results

Table I: Mean and standard deviation of anthropometric measurements of control and sprayer groups
Control group Pesticide sprayer group
Group p value
Mean ± SD (n = 40) Mean ± SD (n = 40)
Age in years 30.35 ± 3.06 31.40 ± 2.78 0.11
Height in cms 167.54 165.98 0.22
Weight in kgs 64.22 ± 3.56 62.52 ± 3.76 0.04*

Table II: Prevalence of respiratory symptoms in control group and study group
Respiratory symptoms Pesticide Sprayers (n = 40) Control Group (n = 40)
sinusitis 22% 7%
rhinitis 11% 3%
sore throat 12% 5%
common cold and fever 6% 2%
dry cough 38% 11%
wet cough 14% 7%
wheeze 28% 2%
heaviness in chest and 11% 3%
dyspnoea 42% 5%

Compared to control in Pesticide Sprayers higher prevalence of respiratory symptoms observed.

Table III: Mean and standard deviation of PFT findings in control and pesticide sprayers
Haematological Control Pesticide Sprayers
t value P value
Parameters (N = 40) (N = 40)
3.43 ± 0.17 2.74 ± 0.19
FVC (L) 16.49 < 0.001***
2.91 – 3.79 2.37-3.08
3.04 ± 0.09 2.42 ± 0.19
FEV1 (L) 17.84 < 0.001***
2.88 -3.19 2.05 -2.76
84.78 ± 2.68 90.33 ± 2.88
FEV1/FVC % 8.91 < 0.001***
80.07 – 94.87 85.41 -96.93
7.33 ± 0.15 5.92 ± 0.12
PEFR (L/S) 44.05 < 0.001***
6.87 – 7.54 5.52 -6.12
3.33 ± 0.07 3.17 ± 0.03
FEF 25-75 (L/S) 12.53 < 0.001***
3.12 – 3.43 3.09 - 3.22
6.01 ± 0.13 4.98 ± 0.06
FEF 0.2-1.2 (L/S) 43.27 < 0.001***
5.83 – 6.42 4.88 – 5.10
101.76 ± 6.83 82.29 ± 12.67
MVV (L/Min) 8.54 < 0.001***
89.23 – 115.16 55.47 -107.33
There was significant decrease observed in In present study Table II shows prevalence of upper
FVC,FEV1,PEFR,FEF25-75,FEF 0.2-1.2 and MVV and lower respiratory symptoms were more in pesticide
while significant increase in FEV1/FVC in pesticide sprayers as compared to control. Organophosphorus
sprayers as compared to control. (OP) pesticides are neurotoxic in nature and they inhibit
acetylcholine esterase enzyme (AChE) by binding with
Discussion its serine residue resulting in excess accumulation of
acetylcholine (ACh) which over stimulate postsynaptic
From table I it was observed that there was no cholinergic nerves.[13] Action takes place on ACh
statistical difference in age and height of control group Muscarinic receptors, either M3 or M2 to affect lung
and pesticide sprayer group (P>0.05). function. M3 receptors are stimulatory which are
present on pulmonary nerves and smooth muscles. FEV1[23,24]FEF25–75%[25]and in MVV.[26,19]Changes in
Over stimulation of M3 receptors by ACh causes FEV1 and FEV1/FVC ratio are related to large airways
contraction of airway smooth muscles.[14]While M2 disease while changes in FEF25–75% is related to
receptors are located on the pulmonary prejunctional small airways disease.[27]Animal studies revealed that
nerves and smooth muscles which can normally inhibit pesticide induces epithelial hyperplasia, thickening of
further release of ACh from prejunctional nerves. It capillary membranes in alveoli which leads to alveolar
was observed in animal studies on guinea pigs that OP derangement and neuromuscular changes in respiratory
pesticides do not inhibit AChE but have potential to muscles.[28]Some of these findings were also observed in
disrupt the autoinhibitory mechanism M2 receptors. earlier studies in India as well as in abroad.[29,17]
[15]
So there was uncontrolled release of ACh from
prejunctional parasympathetic nerves which cause The cause of lung function impairment in present
excessive bronchoconstriction. In present study these study might be due to various adverse effects of
reasons might have induced respiratory symptoms in pesticides on lung structure as discussed above. During
pesticide sprayers. Such respiratory symptoms were spraying of pesticides farmers do not use protective
found by Chitra GA[16]and Khane RS[17] in pesticide devices so there is direct inhalation leading to various
exposed group. Health and hazard surveillance project respiratory defects. They have lack of knowledge about
among Iowa farmers found clear-cut association of safety handling of pesticides which is mainly responsible
respiratory symptoms with pesticides.[18]Absorption for poisoning. Most of them were consuming food
of pesticide is more through lungs than skin, stomach and water in the field during their work. These habits
and intestine. So lung function impairment in farmers may increase the exposure and contamination risk.[30,31]
indicates that exposure of pesticides is mainly through This derangement in PFT parameters in pesticide
inhalation.[19] sprayers may also be due to more and longer duration
of work practices (7-8yrs) as well as in unsafe manner.
Table III shows pulmonary function tests findings in
In general farmers having low educational level, lack
control and Pesticide Sprayers group in which there was
of orientation and technical knowledge about using
highly significant decrease in FVC, FEV1,PEFR,FEF25-
chemicals and low family income might be responsible
75,FEF.2-1.2 and MVV in sprayers compared to
for development of adverse effects on health. This
controls(p <0.001). FEV1/FVC ratio was significantly
scenario strongly points out our social vulnerability to
increased in sprayers compared to controls (p<0.001).
make them aware from careless use of pesticide and
Out of 40 sprayers 12(30%) had purely
higher pesticide exposure. [32,33]
restrictive,24(60%) had mixed type and 4(10%) had
purely obstructive type of lung dysfunction. These In India about 70% of population is depend on
findings suggest that there was restrictive and agriculture for survival so use of pesticides is huge.
obstructive lung function impairment among sprayers [34]
Every year thousands of deaths occur because of
but restrictive type was more predominant. When pesticides poisoning worldwide.[35]This is more common
FEV1/FVC ratio is normal or higher than normal but in developing countries including India. To avoid such
both values (FEV1 & FVC) are reduced then it indicate mortality it is necessary to educate people and make
that there was restrictive deficit.[20]In our study similar them aware about pesticide poisoning. For this purpose
pattern was observed in pesticide sprayers when more and more such type of work is necessarily
compared with control.So in pesticide sprayers there was required.
development of restrictive type of respiratory
impairment.Chakraborty S also found restrictive deficit Conclusions
was more predominant in pesticide exposed group when
compared with controls.[19] Restrictive deficit mainly In present study respiratory status of pesticide
occurs in parenchymal lung diseases when expansion of sprayers was explored. They were from low
lung is reduced due to pneumonia,ILD,sarcoidosis and socioeconomic status. They were not using PPE during
in chest wall abnormalities. On the contrary Fareed M et spraying. They had poor knowledge of hazards of unsafe
al found decrease FEV1/FVC ratio indicating handling and use of pesticides. Majority of them were
obstructive deficit.[21]Previous studies also correlate exposed to pesticides for an average 7-8 years. The
with our findings that there was significant decrease chronic exposure without using safety measures has
in FVC,[22]
caused some derangement of their lung function as 9. Sanzidur Rahman, et al. Farm-level pesticide
accessed by spirometry. This scenario strongly point use in Bangladesh: determinants and awareness.
out our social vulnerability to make them aware from Agriculture, Ecosystem & Environmentb2003;
careless use of pesticide and higher pesticide exposure. 95:241-252.
Periodical assessment of lung function by spirometry
may be advised for early detection of functional 10. Cotes JE. Medical Research Council questionnaire
derangement of lungs. on respiratory symptoms. Lancet.1987;2:1028.
11. Eltayara L, Becklake MR, et al. Relationship
Conflicts of Interest: None
between chronic dyspnoea and expiratory flow
Source of Funding: KIMS Karad limitation in patients with chronic obstructive
pulmonary disease. Am J Respir Crit Care
Ethical Clearance: Institutional Ethical Med
committee(IEC)
1996;154:1726-34.
approval taken priorly.
12. Ferris BG. Epidemiology standardization project.
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DOI Number: 10.5958/0976-5506.2019.01561.4

A Study to Assess the Effectiveness of Planned Teaching

Program on Knowledge Regarding the Care of Permanent
Pacemaker at Home among Patients at Selected OPDs of
Sangli and Kolhapur City

Jesica Dileep Mali1, Sunil. Kulkarni2

1
M.Sc Nursing, 2Associate Professor, Bharati Vidyapeeth (Deemed to be University), College of Nursing
Sangli, Maharashtra

ABSTRACT
Background: A pacemaker is a small electronic device placed just under your skin, above the layer of
muscle. it helps pace your heart in order to keep a healthy heart rate. it senses if the heart is beating too
slowly or pausing too long between heart beats. if it senses a slow rate or a pause that is too long, it will
send electrical pulses to keep your heart rate steady
Methodology: Pre-experimental one group pre test post test was conducted to assess the knowledge of
patients having permanent pacemaker in the selected opds of Sangli and Kolhapur city. The reliability
coefficient ‘r ’of the questionnaire was 0.85, hence it was found reliable. Total 50 samples were selected by
Purposive sampling method. A Structured questionnaire of 18 items was administered to collect data. Pre test
was given on the 1st day followed by planned teaching and Post-test was administering done 7th day. The
conceptual framework based on the general system model theory, developed by Ludwig von bertalanffy
(1968).
Result: Before giving planned teaching patient with permanent pacemaker were unaware of the knowledge
regarding care of pacemaker. It was found maximum patients had good knowledge regarding care of
pacemaker i.e. 10%. The post-test showed that 46% people have good knowledge score. This suggests that
there is marked increase in post-test knowledge score, and planned teaching was effective.
Conclusion: Thus it was conclude that, of the study clearly indicated that there are changes in pre-test and
post-test knowledge score.
Keywords: Knowledge, Planned teaching, pacemaker
Introduction the pathways through which the cutting-edge flows
(coronary heart blocks). Sudden loss of life is one of the
The cardiovascular crisis in India has quadrupled
maximum not unusual motives of death worldwide
inside a conclusive forty years and WHO assesses that
which can be avoided by using placing a pacemaker1.
by 2020 close 60% of heart patients worldwide will
Studies have proved that 60 percent of all unexpected
be Indian. There are unique conditions in which the
cardiac deaths arise because of arrhythmia. Each year 1-
coronary heart may be incapable to regulate the price
2 million individual’s global die because of lack of get
causing a slow heart beat or may display blocks within
admission to pacemakers2. The most often used
implantable gadgets are cardiac pacemakers. A
Corresponding Author: pacemaker is a small electronic device positioned just
Mr. Sunil. Kulkarni, below your skin, above the layer of muscle. It helps
Associate Professor temporary control your heart to be able to hold a
Bharati Vidyapeeth (Deemed to be University) healthful heart rate3. It senses if the heart is beating too
College of Nursing, Sangli slowly or pausing too lengthy among heart beats. If it
Email: [email protected] senses a sluggish charge or a pause that is too lengthy,
it’ll ship electrical pulses to hold your heart
193 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 193

charge steady4. This tool can be temporary or Data collection tool had the questionnaires on care
everlasting, depending at the patient’s condition. of
Teaching patients the critical points regarding to permanent pacemaker at home.
pacemaker control, can save you the complications.
Patients’ schooling has grown to be a critical part of Results
the therapeutic technique to help cardiac patients with
pacemakers. Home fitness care is a particular vicinity of In the present study of patients Before giving
nursing exercise with its roots strongly located in planned teaching patient with permanent pacemaker
network fitness nursing. Home fitness care is that were unaware of the knowledge regarding care of
constituent of comprehensive health care whereby pacemaker. It was found maximum patients had good
fitness services are supplied to sufferers and households knowledge regarding care of pacemaker i.e. 10%.
of their houses to promote, preserve, or repair fitness5. The post-test showed that 46% people have good
knowledge score. This suggests that there is marked
increase in post-test knowledge score, and planned
Materials and Method
teaching was effective. The chi square computed
A present study was conducted by using a between pre-test knowledge and showed that knowledge
quantitative experimental research approach with was dependent on education. But it was not dependent
A Pre-experimental, one group pre-test and pos-test on age, gender, occupation and previous information
design. The conceptual framework was based on general regarding pacemaker.
system model with input, process, output and feedback
developed by Ludwig von bertalanffy (1968). The Findings
reliability was done by using split half method ‘r’ was
Maximum patients 64% belong to the age group
calculated by using Karl Pearson’s formula coefficient
of 51 and above years. 38% of patients had primary
‘r’ of the questionnaire was 0.85, which is more than
education, 56% of patients were male. Maximum
0.70. Validity was done from 28 experts. Proposal with
patients
tool presented in front of ethical committee for
42% belong to other occupation, 100% of patient had
permission. Total 50 samples were selected by non
previous knowledge regarding pacemaker, 44% of the
probability Purposive sampling method. Pilot study was
patients were diagnosed with CHB.
conducted with 5 samples and the study was found
feasible. Final study conducted with same data Section I: Deals with analysis of data related to
collection tool. assessment of the knowledge regarding care of permanent
pacemaker among patients at selected OPDs of Sangli
and Kolhapur city in terms of frequency and percentage.

Table 1: Frequency and percentage distribution Pre- test knowledge score

Groups Scores Frequency Percentage
Poor 0-6 13 26.00
Knowledge - PRE Test
Average 7-12. 32 64.00
Good 13-18 5 10.00

The above table shows that in knowledge scores, at the time of pre test, 26% of subjects were having poor
knowledge, 64% were having average knowledge and remaining 10% subjects were having good knowledge.
Average score at the time of pre test was 8.14.

Table 2: Frequency and percentage distribution Post-test knowledge score

Groups Scores Frequency Percentage

Poor 0-6 0 0.00
Knowledge - POST Test
Average 7-12. 27 54.00
Good 13-18 23 46.00
The above table shows that in knowledge scores, at practicability of research. It was found feasible.
the time of post test, 54% were having average
knowledge and 46% subjects were having good Conflict of Interest: Column is Nil.
knowledge and no one in the poor knowledge group.
Source of Funding: Self.
Average score at the time of pre test was 12.74.
Ethical Clearance: Proposal of research with the data
Discussion collection tool was presented in the front of research
committee for approval prior permission from hospital,
1. The comparative examination was directed were taken. Informed written consent from each
in Specialized Medical Hospital in Mansoura participant was taken. Which included name, number,
University, Trivandrum healing facility. Sample organization, time duration of participation, termination
measure was 35.The outcomes discovered of participation,purpose of the study, incentives,
that about patients has normal dimension of benefits, and where it was promised that there will be no
information in regards to the homecare the board risk to the clients. Principle of confidentiality was
after permanent pacemaker implantation. The attained by giving code number to data collection tool.
examination reasoned that there is no factual The received information also kept confidential.
connection between information of homecare the Ethical clearance is done with the committee members
executives of permanent pacemaker implantation Dr.Sripriya and Dr.NilimaBhore mam.
patients and related factors like age instructive
capabilities and year of pacemaker implantation19.
REFERENCES
2. The comparative examination was led in
Mansoura University. the investigation 1. Mrs. Sreelekshmi. V, A STUDY TO ASSESS
uncovered that there was a factually critical THE KNOWLEDGE OF HOMECARE
contrast in patient’s information and practice. MANAGEMENT OF PERMANENT
Sample estimate was mPACEMAKER IMPLANTED PATIENTS.
50.More patients had lacking (learning and work project report, November 2011.
on) with respect to pacemaker pre actualizing 2. Suleyman Ercana,n, Gokhan Altunbasb, Fethi
instruction program. After Educational program Yavuza, Vuslat Bosnakc, Vedat Davutoglua,
had factually noteworthy beneficial outcome on Permanent pacemaker lead endocarditis due
patient’s execution (information and practice) to Staphylococcus hominis and review of the
with lasting Pacemaker. literature, coretvasa 54 (2012) e336–e338.
3. Dan Malm, Anna Sandgren1. Regaining
Conclusion Normalcy in Relatives of Patients with a
Pacemaker. Open Journal of Nursing, 2014, 4:
The present study concludes with the purpose of
139-149
finding the effectiveness of planned teaching program on
knowledge regarding the care of permanent pacemaker 4. Hanaa, A, A. Yossif 1 & Ebtisam, M. Abd El-
at home among patients at selected opds of sangli and aal. Home Care for Patients with Permanent
Kolhapur city Findings of the study clearly indicated that Pacemaker Insertion. IOSR Journal of Nursing
there are changes in pre-test and post-test knowledge and Health Science 2017july-aug.6(4): 49-57
score. www.iosrjournals.org.

The design used for the study was A Pre- 5. Jason J. Roedig, DMD1 Jignesh Shah, MD2
experimental, one group pre-test and pos-test design was Claude Samy Elayi, Interference of cardiac
used. The study was conducted at selected opds of sangli pacemaker andimplantable cardioverter-
and Kolhapur city. The Sample size of the study was 50 defibrillator activity during electronic dental
patients of permanent pacemaker device use.the journal of the American Dental
Association.2010,141:512-526
The reliability of the tool was determined Split Half
6. Trigano A, Blandeau O, Dale C, Wong MF, Wiart
Method of Reliability, the tool was administered to 5
J.reliability of electromagnetic filters of cardiac
samples. Reliability of the knowledge tool was found to
pacemakers tested by cellular telephone ringing
be 0.85.
pubmed heart rhythem 2005 aug.2(8):837-841
The pilot study was conducted, to assess the www.ncbi.nlm.nih.gov/pubmed/16051120
feasibility
of the study and to decide the statistical analysis and
DOI Number: 10.5958/0976-5506.2019.01562.6

A Study to Assess the Effectiveness of Planned Teaching

Programme on Knowledge Regarding Selected Pediatric
Emergencies among Mothers of Under Five Children
at Selected Anganwadi’s of Sangli, Miraj and Kupwad
Corporation Area

Jesica Prashant Malap1, Shaila Mathew2

1
M.Sc Nursing, 2Assistant Professor, Bharati Vidyapeeth (Deemed to be University) College of Nursing,
Sangli

ABSTRACT
A quantitative study was conducted by Mrs. Jesica P. Malap. out with the purpose of increasing awareness
of Pediatric emergencies in public thereby reduces the morbidity and mortality in children.
Objectives:
1. To assess the knowledge of mothers regarding selected pediatric emergencies.
2. To assess the effectiveness of planned teaching programme regarding pediatric emergencies
3. To find out the association of pre-test knowledge score with selected demographic variables.
Materials and Method: A quantitative pre-experimental one group pre-testpost-test design was used to
assess the knowledge of mothers having under five children in the selected anganwadi’s of Sangli, Miraj
and Kupwad corporation area. The conceptual framework based on the Goal attainment theory, developed
by Modified Imogene king’s (1960), with perception, action, interaction and transaction or goal attainment.
The reliability was done by using test-retest method ‘r’ was calculated by using Karl Pearson’s formula
coefficient’s’ of the questionnaire was 0.9, hence it was found reliable. Validity was done from 25 experts.
Total 80 samples were selected by Probability simple random sampling method. A Structured questionnaire
of 24 items was administered to collect data. Pre-test was given on the 1st day followed by planned teaching
and Post-test was administered on seventh day.
Results and Conclusion: Data were analysed by using frequency and percentage for demographic
variables. Compute frequency, percentage, mean, standard deviation used to calculate pre-test and post-test
knowledge score. Paired ‘t’ test was used to compare the pre and post-test knowledge score. Chi square
test was used to find association between demographic and pre-teat knowledge score. It was found
maximum mothers
63.75% were having average knowledge score. The post-test showed that, 82.50% have good knowledge
score. This suggests that there is marked increase in post-test knowledge score, and planned teaching was
effective. The chi square computed between pre-test knowledge and showed that knowledge was dependent
on age and education of mothers. But it was not dependent on monthly income, type of family.

Keywords: Knowledge, Planned teaching, Paediatric emergencies.

Introduction
Corresponding Author:
Mrs Shaila Mathew Children are not like adults. Physiologic, Cognitive
Assistant Professor and Psychosocial differences affects a child’s perception,
Bharati Vidyapeeth (Deemed to be University) reaction to illness or injury, communication patterns and
College of Nursing, Sangli-416416 coping abilities. To determine a child’s health status
Email: [email protected] and individual needs, knowledge of normal growth
196 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 196

and development, careful observation of behaviour and by using test-retest method ‘r’ was calculated by using
physiologic cues and listening to the primary care givers Karl Pearson’s formula coefficient’s’ of the questionnaire
are important. To facilitate positive outcomes, health was 0.9, hence it was found reliable. Validity was
care provider need to understand the unique done from 25 experts. Total 80 samples were selected
characteristic of children2. by Probability simple random sampling method. A
Structured questionnaire of 24 items was administered
Children are a high risk group to encounter
to collect data. Pre-test was given on the 1st day followed
accidents and injuries. They are achieving more skills
by planned teaching and Post-test was administered on
and they want to explore many things as they grow.
seventh day.
Most of the time under five children are unaware about
the consequence of their activities. A proper first aid
management in the right time will save the valuable Results
life of our future generation. Every year huge number
Section II: Frequency and Percentage Distribution
of deaths are happening around the globe. A Pre test Knowledge Score
paediatric
emergency is a serious condition that threatens the life
of an infant, child, teen, or young adult thus require
immediate medical attention 3.Pediatric emergencies Table 1: Pre- test knowledge score
can be caused by a particular illness, an injury or n = 80
by ingesting a foreign object or poison. Paediatric
emergencies like burn injury, poisoning, foreign body Grading Frequency Percentage
aspiration and epistaxis are few examples where the Poor (0-8) 27 33.75
child needs to be managed immediately and promptly. Average (9-16) 51 63.75
Each year, among those 0 to 5 years of age, more than
Good (17-24) 2 2.50
12,000 people die from unintentional injuries and more Table no.1 shows that 33.75% mothers have poor
than 9.2 million are treated in emergency departments knowledge score, 63.75% and 2.50% mothers were
for nonfatal injuries. It is widely recognized that children having good knowledge score. Minimum score is 2 and
have unique needs, particularly when they require maximum is 18. Average score at the time of pre- test
immediate medical attention. The first person to notice was 9.97. It is evident that more efforts are necessary to
that the child requires emergency medical assistance, improve the knowledge regarding pediatric emergencies
should administer first aid procedures while waiting for among mothers of under five children.
emergency medical personnel to respond. Therefore,
adults with children in their homes should be aware of Section III: Frequency and Percentage Distribution
basic first aid procedures and be familiar with the of Post test Knowledge Score
characteristics of an emergency. Managing these
emergencies is an important area where the family
Table 2: Post-test knowledge score
members should be involved in caring for a child, thereby
n = 80
reducing the mortality rates and lifelong disabilities4.
Grading Frequency Percentage (%)
Materials and Method Average (9-16.) 14 17.50
Good (17-24) 66 82.50
A quantitative pre-experimental one group pre-
test post-test design was used to assess the knowledge Table no.2 shows that mother at the time of post-
of mothers having under five children in the selected test 17.50% were having average knowledge, 82.50%
anganwadi’s of Sangli, Miraj and Kupwad corporation subjects were having good knowledge and none of the
area. The conceptual framework based on the Goal mothers have poor knowledge score. Minimum score is
attainment theory, developed by Modified Imogene 10 and maximum score is 23.Average score at the time
king’s (1960), with perception, action, interaction and of pre-test was 17.90. This suggests that there is marked
transaction or goal attainment. The reliability was done increase in post-test knowledge score.
Section III: Comparision between Pre-test and Post- Table no. 3 demonstrates that, mean estimation
test Knowledge Score of pre-test information score is 9.97with standard
deviation of 3.69 and post-test information is 17.9 with
Table 3 standard deviation of 2.61. The test insights estimation
n = 80 of the matched t test was 22.01 with p esteem 0.00.
This recommends there is factually critical increment
Mean S.D. S.E. t value P value in post test score so arranged showing program (PTP)
Pre Test 9.97 3.69 0.41 on information with respect to pediatric crises among
22.01 0.000
Post Test 17.9 2.61 0.29 mothers of under five children was powerful.

Section V: Association between Demographic Varibles with Pre-test Knowledge Score

Table 4: Association with demographic variables and pre -test

n = 80
Sr. No. Demographic Variable Chi Square d.f p-value Remark
1. Age of mothers 19.59 6 0.003 Significant association.
2. Education 25.36 8 0.001 Significant association.
3. Monthly income 4.35 6 0.629 No Significant association.
4. Type of Family 2.27 2 0.321 No Significant association.
Table no. 4 indicates that there is significant group 15001-20000, 25% were having income of 20001
association between age of mother and education with and above, 23.75% were in 10001-15000 and 22.50%
the pre-test knowledge score as calculated ‘p’value is were in the 5000-10000 income group. In type of family
less than tabulated (0.05) value. There is no significant most of the mothers,58.75% belongs to nuclear family
association between monthly family income, type of and rest mothers 41.25% were from joint family3.
family with pre-test knowledge score as calculated ‘p’
value is more than tabulated (0.05) value. It was the found that maximum children 38.75%
were in the age group of 2-3 years of age, 35% of
children belongs to the age group of 3-4 years, 20 %
Discussion
children belongs to age group of 5 years and remaining
A study was conducted to assess the effectiveness 6.25% were in the age group below one year of age. In
of planned teaching programme on knowledge regarding the gender of child the maximum, 58.75% were having
selected pediatric emergencies among mothers of under female children and 41.25% mothers have male
five children at selected anganwadi’s of Sangli, Miraj children. As per birth order most of the children 45%
and Kupwad corporation area. The findings of the study were second child, 35% were first child and 20% were
have been discussed based on the objectives and the third child to their parents.5
hypothesis of the study.
In the present investigation, the pre-test information
It was found that, 36.25% of mothers belonged to score with respect to pediatric crises in children was
the age group of 25-31 years, 30% of mothers belonged gathered by organized survey was utilized to gather the
to the age group of 33-38 years of age, 22.2% of information. The overall score was 24 and was separated
mothers belonged to the age group of 18-24 years and 0-8 (poor), 9-16 (normal), 17-24 (great). It was discovered
11.25% belonged to the age group more than 39 and that, 63.75% mother were having normal learning score,
above. Maximum mothers 38.75% have secondary 33.75% of mother were having poor knowledge score and
education, 2.505 of mothers have good knowledge score. Minimum
23.75% mothers were graduates, 22.50% were score is 2 and most maximum score is 18. Normal score
having at the season of pre-test was 9.97. Around the same time
primary education, 8.75% were post graduates and only arranged educating was taught to mothers 6.
6.25% mothers had not taken any formal education. As
per monthly income most 28.75% was in the
income
The equivalent organized poll was utilized to gather Conclusion
the information after arranged instruction with the
interim of 7 days post-test were directed. It was The present study concludes with the purpose of
discovered that finding the effectiveness of planned teaching programme
82.50% of mothers were having great learning on knowledge regarding selected pediatric emergencies
score, among mothers of under five children at selected
17.50% were having normal information score and none anganwadi’s. Findings of the study clearly indicated that
of the mothers have poor learning score. Most maximum there are changes in pre-test and post-test knowledge
score was 23 and least score was 10 Normal score at the score.
season of post-test was 17.90. This recommends there is
Conflict of Interest: Nil.
checked increment in post-test information score.
Source of Funding: Self.
The mean value of pre-test knowledge score is 3.69
and post knowledge score is 17.9, standard deviation Ethical Clearance: Proposal of research with the data
score in the pre-test phase was 3.69 and in the post test collection tool was presented in the front of research
was 2.61. Calculated ‘t’ value is 22.01 which is more committee for approval prior permission from hospital
than the tabulated ‘t’ value and calculated value is 0.000 and child development officer, were taken. Informed
which is less than tabulated ‘ p’ value (0.05). This written consent from each participant was taken. Which
suggests that there is statistically significant increase in included name, number, organization, time duration of
post test score so planned teaching programme on participation, termination of participation, purpose of the
selected pediatric emergencies in children among study, incentives, benefits, and where it was promised
mothers of under five children was effective. that there will be no risk to the clients. Principle of
confidentiality was attained by giving code number to
The chi-square test was used to find out the
data collection tool. The received information also kept
association between demographic variables with pre-
confidential. Ethical clearance is done with the committee
test knowledge score. In age of mother ‘x2’ value is 19.59
members Dr. Sripriya and Dr. Nilima Bhore mam.
and ‘p’ value is 0.03 which is less than 0.05 so there is
significant association between age of mothers with
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survey at the united Christian hospital”, Hong 14. ELIZABETH PATON. Medical_Specialty
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[http:// 2012. [Citated 2012]. Avaliable from: http://
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10. Chirag A Bhansali, Giriraj Gandhi, Parag 15. Karraebed. Child Development. [Internet].
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study of burn injuries and its mortality risk Available from: https://en.wikipedia.org/wiki/
factors in a tertiary care hospital [Internet]. Indian Child_development
Journal of Burns.2017 [Cited 13 December 2017],
Available form : http://www.ijburns.com
DOI Number: 10.5958/0976-5506.2019.01563.8

Comparative Evaluation of the Effect of Radiation Therapy on

Surface Micro Hardness of Three Restorative Materials— An
in Vitro Study

Karthik Shetty1, Mary Byju1, Chong Hao Phin1, P U Saxena2, Challapalli Srinivas2
1
Department of Conservative dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore,
2
Department of Radiotherapy, Kasturba Medical College, Mangalore, (Affiliated to Manipal Academy of
Higher Education, Manipal), Light House Hill Road, Mangalore, Karnataka, India

ABSTRACT
Context: Dental restorations in Patients undergoing radiotherapy for the treatment of Malignancies
may
undergo changes in their physical properties due to the irradiation.
Aims: To investigate the effect of Gamma irradiation applied during cancer radiation therapy on the surface
microhardness of Cention N, Zirconomer and 3M Filtek Bulkfil Posterior Packable Composite.
Settings and Design: In-vitro study conducted in a Dental school.
Method and Material: Twenty specimens of each material were prepared within acrylic moulds and these
were divided into six groups with 10 of each restorative material per group. Groups 1, 2, and 3 were not
subjected to any intervention whereas Groups 4, 5 and 6 were subjected to the radiotherapy protocol which
is used on patients with malignancies.
Statistical Analysis Used: Two-way repeated ANOVA and Tukey’s
test.
Results: After irradiation the comparative changes in the surface microhardness in all the groups were
statistically significant. The values of surface hardness of the Filtek group remained the highest followed by
the Cention and Zirconomer groups.
Conclusions: The conclusion than can be drawn from this study are that the exposure to Gamma radiation
does affect the surface hardness of the materials tested.
Keywords: Surface micro hardness, Therapeutic ionising radiation, Vickers hardness
test.

Introduction that are in clinical use. The surface Hardness of a

dental restorative material is an important property
The physical properties of the restorative materials
while selecting replacement options for the lost tooth
are of perpetual interest to the restorative dentist.
structures such as the enamel as the mechanical role of
Research in dental materials aims to continuously push
enamel is crushing food. (1)Surface hardness is a factor
the limits and increase the durability of the
often used to assess the surface resistance of a material
materials
to plastic deformation by penetration. Amalgam has
been the gold standard in restorative dentistry and has
Corresponding Author: over the years vindicated its tag as the most durable
Dr Karthik Shetty of restorative materials, but due to its grey color and
Department of Conservative Dentistry and Endodontics safety concerns it is being gradually replaced now by
Manipal College of Dental Sciences, Mangalore newer tooth colored restorative materials. Three recent
Manipal Academy of Higher Education, alternatives to amalgam that claim to have high strength
Manipal-576104, Karnataka, India for their use in posterior stress bearing areas are Cention
Phone: +91- 824- 2423452/2428716(Ext: 5665) N, Zirconomer and Bulk fill composites.
Email: [email protected]
201 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 201

Direct dental restorations are routinely indicated Radiation Protocol: Ten samples of groups 4, 5, 6 were
for restoring teeth with caries prior to head and neck irradiated with 70 Gy of 6 megavoltage radiation using
radiotherapy. Radiotherapy of head and neck region can ELEKTA COMPACT linear accelerator, 2 Gy daily, 5
cause changes in the oral environment such as drop in days per week for a total of 7 weeks (35 fractions) at the
pH, xerostomia and structural changes of organic and
Department of Radiotherapy and Oncology.The samples
inorganic portion of mineralized tissues; degenerative
were immersed in a water phantom during irradiation.
and inflammation processes are also observed.(2)(3) The
This protocol is the same as the one used in patients
durability of dental materials is influenced by its intrinsic
properties and by the environment to which they are under oncogenic treatment for head and neck tumors.
exposed to. Studies done by Aoba et al has proved the
Microhardness Testing: The Vickers hardness test
occurrence of physical and chemical changes that modify
method involves the indenting of the test material with
the mechanical properties of restorative materials in
irradiated teeth.(4) Ideally the material to be used ina diamond indenter, in the form of a right pyramid with
patients undergoing radiation should bond to tooth a square base and an angle of 136 degrees between
opposite faces subjected to a load of 1 to 100 Kg. The
structure, check secondary caries, repel dehydration and
acid erosion.(5) load is normally applied for 10 to 15 seconds. After the
removal of the load the two diagonals of the indentations
The aim of this study is to assess how the impact created on the surface of the materials are measured using
of gamma radiation affects the micro hardness of three a microscope and their average is calculated. The area of
different restorative materials: Cention N, Zirconomer
the sloping surface of the indentation is then calculated.
and 3M Filtek Bulk Fill Posterior Packable Composite.
The null hypothesis tested was that exposure to the Data Management and Statistical Analysis: The
irradiation process will not bring about any variation mean values of various materials at different immersing
in the surface microhardness of the three restorative times were compared by one-way analysis of variance
materials being examined.
(ANOVA), and multiple comparisons of mean were
performed using Tukey’s test and the level of p < 0.001
Materials and Method was regarded as significant.
Specimen Preparation: Ten specimens of each Ethical Considerations: Ethical clearance to conduct
restorative material were made within acrylic molds the study was obtained from the Institutional Ethics
in the dental laboratory. The dimensions of each Committee of the dental college.
specimen was 6mm in diameter and 3mm in thickness.
A polyethylene sheet and a glass slide was positioned
Results
over the filled mold after which light pressure was
applied. This method provided an even surface on every In this experimental and comparative in vitro
specimen. study, all data showed normal distribution. The mean
values of Vickers hardness before radiation exposure
The Specimens were allocated into six groups
are summarized in Table 1. Prior to irradiation
Group 1: Cention N without irradiation for 7 weeks Group
(n=10) 3 exhibit the highest VHN (Harder) followed by Group
1 and Group 2. The comparative changes in the surface
Group 2: Zirconomer without irradiation for 7 weeks micro hardness of Group 1, Group 2 and Group 3
(n=10) following the exposure to radiation were statistically
significant (p=.011) (Table 2).After irradiation the
Group 3: 3M Filtek Bulk Fill Posterior Packable values of surface hardness of the Filtek group remained
Composite without irradiation for 7weeks (n=10) the highest followed by the Cention and Zirconomer
Group 4: Cention N with irradiation for 7 weeks (n=10) groups. When the results of the pre and post radiation
values were compared against each other, there was a
Group 5: Zirconomer with irradiation for 7 weeks comparative reduction in the Vickers hardness values
after radiation in the Cention and Filtek groups, whereas
(n=10) Group 6: 3M Filtek Bulk Fill Posterior the Zirconomer group showed an increase in the

Packable microhardness values following irradiation (Graph 1).

Composite with irradiation for 7 weeks (n=10)
Table 1: The mean and standard deviation values of Vickers hardness before radiation exposure are
tabulated
MICROHARDNESS PRE RADIATION
N Mean Std. Deviation Minimum Maximum
Cention 10 52.3500 2.85113 47.17 56.13
Zirconomer 10 46.5667 2.91395 43.07 51.40
Filtek 10 77.6433 5.86848 69.27 86.17

Table 2: The mean and standard deviation values of Vickers hardness after radiation exposure are tabulated
MICROHARDNESS POST RADIATION
N Mean Std. Deviation Minimum Maximum
Cention 10 51.927 4.302 44.73 58.47
Zirconomer 10 48.410 4.399 42.17 55.53
Filtek 10 72.657 7.164 62.70 83.07

Graph 1: The comparative changes in Vickers hardness value before radiation and after radiation are depicted

Discussion (EMFs) on animal models and humans have been

studied extensively over the years.(13)(14)(15)(16)(17)(18)(19)(20)
Therapeutic ionising radiation is used for
But we did not come across any studies on the effect
radiotherapy in the treatment of head and neck cancers.
of Gamma radiation on dental restorative materials in
The risk of developing caries is substantially increased
our literature search. In the current study the dosage of
for their lifetime in patients of radiation therapy. This
radiation which the restorative materials were subjected
is as radiation causes a direct alteration in the enamel
to was planned to replicate the clinical scenario.
and dentin ultrastructure, Chemical alterations in the
tissues, Morphological alterations of enamel and dentine In the present study Filtek exhibited the highest
structures and decrease in dentinal microhardness(6)(7) (8)(9) values for surface microhardness in the pre testing
(10) (11)(12)
. Since radiation produces such structural before irradiation, followed by Cention and
changes and alterations in the mechanical properties of Zirconomer. After irradiation the values of surface
enamel and dentin, we can also expect some changes hardness of the Filtek group remained the highest
to occur in the restorative materials too. The effects of followed by the Cention and Zirconomer groups. The
exposure to different sources of electromagnetic comparative changes in the surface microhardness of
fields the groups were statistically
significant. The results showed a comparative reduction 7. Jansma, J., J. M. P. M. Borggreven, and F. C. M.
in the Vickers hardness value after radiation in the Driessens. “Effect of X-ray irradiation on the
Cention and Filtek groups. But the Zirconomer group permeability of bovine dental enamel.” Caries
showed an increase in the microhardness values research 24.3 (1990): 164-168.
following irradiation.
8. Soares, C. J., et al. “Scanning electric microscopy
used to analyze the effect of gamma irradiation
Conclusion on enamel and dentin.” Microscopy: science,
technology, application and education. A
The conclusion than can be drawn from this study
Mendez– Vilas and J Diaz (2010): 372-8.
are that Filtek bulkfil composite will be the material of
choice if strength is desired from the restoration as it 9. Gonçalves, Ligia Maria Napolitano, et al.
continued to be the hardest material even after “Radiation therapy alters microhardness and
irradiation. But Zirconomer can be considered as a microstructure of enamel and dentin of permanent
viable alternative as it showed no regressive changes human teeth.” Journal of dentistry 42.8
following irradiation rather an increase in the hardness (2014):
values of the material was noted. 986-992.

Conflict of Interest: The authors have no conflict 10. de Siqueira Mellara, Talitha, et al. “The effect
of of radiation therapy on the mechanical and
interest to disclose. morphological properties of the enamel and dentin
of deciduous teeth—an in vitro study.” Radiation
Source of Funding: Self. Oncology 9.1 (2014): 30.
11. Gonçalves, Ligia Maria Napolitano, et al.
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“Comparative study of mechanical properties human teeth.” Journal of dentistry 42.8
of dental restorative materials and dental hard (2014):
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biomechanics 5 (2014). 12. Kielbassa, Andrej M., et al. “Irradiation effects on
2. Wanebo, Harold J., et al. “T-cell deficiency in microhardness of fluoridated and non‐fluoridated
patients with squamous cell cancer of the head bovine dentin.” European journal of oral sciences
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130.4 (1975): 445-451. 13. Mortazavi, S. M. J., et al. “Non-linear adaptive
3. Martin, M. V. “The role of oral microorganisms phenomena which decrease the risk of infection
in cancer therapy.” Current opinion in dentistry 2 after pre-exposure to radiofrequency radiation.”
(1992): 81-84. Dose-Response 12.2 (2014): dose-response.

4. Aoba, Takaaki, et al. “High-voltage electron 14. Mortazavi, S. M. J., et al. “Non-linear adaptive
microscopy of radiation damages in octacalcium phenomena which decrease the risk of infection
phosphate.” Journal of dental research 60.5 after pre-exposure to radiofrequency radiation.”
(1981): 954-959. Dose-Response 12.2 (2014): dose-response.

5. Hu, J‐Y, et al. “Restoration of teeth with more‐ 15. Mortazavi, S. M. J., et al. “Human short-term
viscous glass ionomer cements following exposure to electromagnetic fields emitted by
radiation‐induced caries.” International dental mobile phones decreases computer-assisted visual
journal 52.6 (2002): 445-448. reaction time.” Acta neurologica belgica 112.2
(2012): 171-175.
6. Jervøe, Peter. “X-Ray Diffraction Investigation on
the Effect of Experimental and in Situ Radiation on 16. Mortazavi, S. M. J., et al. “Increased
Mature Human Teeth a Preliminary Report.” Acta radioresistance to lethal doses of gamma rays in
Odontologica Scandinavica 28.5 (1970): 623-631. mice and rats after exposure to microwave
radiation emitted by a GSM mobile phone
simulator.” Dose-response
11.2 (2013): dose-response.
17. Mortazavi, S. M. J., et al. “A comparative study among university students.”
on the increased radio resistance to lethal doses of Bioelectromagnetics: Journal of the
gamma rays after exposure to microwave Bioelectromagnetics Society, The Society for
radiation and oral intake of flaxseed oil.” Physical Regulation in Biology and Medicine,
International Journal of Radiation Research 9.1 The European Bioelectromagnetics
(2011): 9. Association28.4 (2007): 326-330.
18. Mortavazi, Seyed, et al. “Alterations in TSH and 20. Mortazavi, Seyed Mohammad Javad. “Does
thyroid hormones following mobile phone use.” the ringtone or radiofrequency radiation of a
Oman medical journal24.4 (2009): 274. mobile phone affect reaction time of its owner?”
19. Mortazavi, S. M. J., J. Ahmadi, and M. Shariati. International journal of occupational medicine
“Prevalence of subjective poor health symptoms and environmental health 27.1 (2014): 149-150.
associated with exposure to electromagnetic fields
DOI Number: 10.5958/0976-5506.2019.01564.X

Evaluate the Association between Acrochordons and Systemic

Diseases

Malar Mangai E.1, Harsha Vardhan K.2, Bhuvanarachagan A.3

1
PG Student of Dermatology, 2Professor and HOD of Dermatology, 3Associate Professor of
Dermatology, Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry

ABSTRACT
Acrochordons are associated with conditions like pregnancy, intestinal polyps, growth disorders, metabolic
syndromes, atherosclerosis and various other syndromes including polycystic ovarian syndrome, Birt–
Hogg–Dubé syndrome, and Cowden syndrome. This study was carried out as a cross sectional study in a
Teaching hospital. This study was undertaken in the outpatient Department of Dermatology in our Teaching
hospital. This study was carried out for a period of seven months between October 2017 and April 2018.
Our study demonstrated the association of skin tags with certain systemic conditions. Our study
demonstrated statistically significant results with uncontrolled diabetes mellitus. Studies have demonstrated
that multiple skin tags are often associated with insulin resistance and obesity. Our study demonstrates the
significant relationship between history of cardiovascular diseases, hypercholesterolemia, and the
presence of skin tags, which has been substantiated by several other studies. While diabetes mellitus,
hypertension and cardiovascular diseases were definitive risk factors, our study could not demonstrate
significant association between obesity and acrochordons.
Our study may be taken as the basis for using acrochordons as an effective screening tool for several
non- communicable diseases like diabetes mellitus, hypertension, cardiovascular diseases and uncontrolled
diabetes.

Keywords: Acrochordons, Diabetes Mellitus, insulin resistance, Metabolic Syndrome,

Obesity.
Introduction Growth Factor (TGF) and Epidermal Growth Factor
(EGF)are also implicated in the incidence of skin tags. 1
There are several systemic infectious diseases and
syndromes associated with skin tags. Skin tags are Birt–Hogg - Dube- syndrome is characterized by
associated with conditions like pregnancy, intestinal multiple fibrofolliculomas and trichodiscomas. They are
polyps, growth disorders, metabolic syndromes, similar to acrochordons. Birt – Hogg - Dube- syndrome
atherosclerosis and various other syndromes including is caused by mutation of FLCN gene that produces
polycystic ovarian syndrome, Birt–Hogg–Dubé folliculin which is a tumor suppressor protein. There has
syndrome, and Cowden syndrome. Some of the been significant association between Birt – Hogg - Dube-
infections which correlate with skin tags include human syndrome and Pneumothorax and renal cell carcinoma. In
papilloma virus, which is said to occur in 88% of the addition to this, one of the variants of basal cell
acrochordons. Certain variations in the estrogen levels carcinoma also present with clinical similarities of
and hormones such as IGF-1, Insulin and Transforming acrochordons. The fibroepithelioma of Pinkus is a sub
type of basal cell carcinoma which often presents as pink
acrochordons and form an important differential
Corresponding Author: diagnosis. An increased irritation of the skin due to skin
Dr. Harsha vardhan. K stretching in obese individuals may result in polypoid
Professor and HOD of Dermatology, formations for which several factors are often involved.
Sri Lakshmi Narayana Institute of Medical Sciences, Some of the factors suggested include hormonal
Puducherry imbalance, since the genetic material from the viral
Email: [email protected] pathogens has been identified in many samples of skin
tags.2
206 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 206

Acrochordons have been linked to the appearance combination 7.Metabolic syndrome and several other
of malignancies with other organs like kidney and non-communicable diseases are silent killers with a
gastrointestinal tract because of abnormal activity of long latent period and dreadful, morbid complications
Epidermal Growth Factor (EGF) & Tissue Growth affecting various systems like heart, brain, kidneys, etc.
Factor (TGF) which are released by these tumors. The
other important biological condition which is associated There are very few predictors for non-
with Acrochordons is Type 2 diabetes mellitus. This is communicable diseases, which help clinically detect the
due to the presence of insulin resistance. Acrochordons ongoing risk of a non-communicable disease. Studies
in acanthosis nigricans which is a common feature of have implicated that skin tags or acrochordons are
insulin resistance and type 2 diabetes mellitus. potential predictors of the risk of these non-
communicable diseases. Acrochordons are easily
Metabolic syndrome is a clustering of various identified by clinical examination and individuals can
pathologies of metabolic origin and are accompanying be educated to use this as a potent screening tool for
by increasing risk of cardiovascular diseases and detecting systemic diseases. This study is expected to
type implicate the magnitude of clinical risk of these diseases
2 diabetes mellitus. Metabolic syndrome is commonly in the presence of acrochordons. The aim of this study is
presented as obesity, atherogenic dyslipidaemia, to clinically evaluate associated factors of acrochordons
elevated blood pressure and raised plasma glucose 3. The along with the prevalence of systemic diseases.
other essential component of metabolic syndrome which
affects the skin diseases are oxidative stress. Oxidative
Material and Method
stress, is a condition where the relative imbalance
between reactive oxygen species and antioxidants. This This study was carried out as a cross sectional study
is believed to play a major role in the pathogenesis in a Teaching hospital. This study was undertaken in the
of metabolic syndrome. The other factor associated outpatient Department of Dermatology in our Teaching
with metabolic syndrome is endocrine abnormality. hospital. This study was carried out for a period of seven
Intra abdominal fat in endocrine organs capable of months between October 2017 and April 2018. The
secreting proteins such as adiponectin and Leptin study population consisted of all the patients who visited
promote inflammation, altered glucose metabolism and the outpatient department during the study period.
vascular endothelial biology. Obesity may be defined
Obtained Ethical Clearance from Institutional Ethics
as an abnormal growth of the adipose tissue due to an
Committee, prior to the commencement of the study.
enlargement of fat cell size or an increase in the fat cell
Each participant was explained in detail about the study
number or a combination of both. 4 Obesity is also found
and informed consent was obtained prior to the data
with mixed color skin tags and has been hypothesized to
collection. The participants were selected using
occur due to interaction of mast cells and melanocytes
purposive sampling amongst the patients who visited the
for post inflammatory pigmentation 5. Insulin is the
outpatient clinic of our Dermatology Department.
hormone that promotes tissue growth and stimulates
glucose uptake in tissues at an intensity that varies from Inclusion Criteria: Adults above 18 years of age. Both
individuals. Adult patients with acrochordons should Sexes.
be alerted in risk of development of insulin resistance,
hypertriglyceridemia, diabetes mellitus in the light of Exclusion Criteria: Children and Patients presenting
obesity and overweight. They are at increased risk of with generalized skin disease like psoriasis,
developing cardiovascular complication like myocardial Erythroderma, Immunobullous disorder, etc.
infarction, cerebrovascular disease, Peripheral arterial
disease, erectile dysfunction, Cognitive decline, fatty Statistical Analysis
liver and reno-vascular diseases. 6
Data was entered and analyzed using SPSS version
Overall skin tags occur as a result of impaired 15 software. Percentages and Chi – square were used
carbohydrate or lipid metabolism or liver enzyme to describe the prevalence of skin tags and systemic
abnormalities or hypertension. Studies have proven diseases. A p value less than 0.05 was considered to be
that skin tags are associated with various components statistically significant.
of metabolic syndrome either individually or in

Results
207 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 207
This cross-sectional study was carried out
among
150 participants visiting the outpatient clinic of our
department. The consent form was given to the patients
prior to the interview. A structured interview schedule
was used to elicit history regarding the medical
conditions. Each participant was clinically examined for
skin tags. Random blood sugar was estimated to assess
the status of diabetic control. Majority of the
participants belonged to the age group of >40 years
(75.3%). Males were about
104 (69.33%) while females were 46 (30.67%). The
Figure 1: Distribution of the body mass index of the
body mass index of the participants showed that
study participants
majority
of the participants were overweight (23.7%). (Figure 1).

The association between background risk factors and acrochordons show that males are at increased risk
for acrochordons (16.3%). However, the observed difference was statistically not significant. Participants with
overweight and obesity were at an increased risk for acrochordons (16.7% and 14.4% respectively) compared to
participants with normal BMI. However, the observed difference was statistically not significant. Our study also
showed that uncontrolled diabetes mellitus (RBS>200 mg/dl) was not significantly associated with acrochordons
(p<0.520). (Table 1)

The association between history of medical conditions and presence of acrochordons shows that known history
of cardiovascular diseases was a significant risk factor (75.0%) for acrochordons compared to participants without
history of cardiovascular diseases (12.4%). The observed difference was found to be statistically significant
(p<0.05). Moreover, history of hypertension was a significant factor for acrochordons. It was observed that
participants with known history of hypertension were significantly associated with acrochordons (29.6%) compared
to those with no history of hypertension (10.6%). The observed difference was found to be statistically significant
(p<0.05). (Table 2)
Table 2: Association between medical history and Acrochordons

S. Acrochordons
Parameters N (150) Chi sq P value
No. Present n (%) Absent n(%)
1. History of cardiovascular diseases
Present 3 (75.0) 1 (25.0) 4
12.7 0.001*
Absent 18 (12.3) 128 (87.7) 146
2. History of hypertension
Present 8 (29.6) 19 (70.4) 27
6.6 0.010*
Absent 13 (10.6) 110 (89.4) 123
3. History of diabetes mellitus
Present 5 (19.2) 21 (80.8) 26
0.7 0.398
Absent 16 (12.9) 108 (87.1) 124
4. History of endocrine disorders
Present 0(0.0) 2 (100.0) 2
0.3 0.566
Absent 21 (14.2) 127 (85.8) 148
*statistically significant
Discussion with no history of hypertension (10.6%) The association
was found to be statistically significant (p< 0.001)
In our study one of the objectives was to evaluate
the association of acrochordons and the risk factors. Our study findings were similar to other studies
The association between demographic risk factors and 8-9
done by Maluki et al BMI, Blood Pressure, and
the skin tags was carried out and it was observed that Metabolic Syndrome correlated significantly in the
male participants were at an increase the risk of having presence of skin tags (p<0.005) and El Safouri et al BMI
skin tags compared to female participants. However, was found to be a significant risk factor for skin tags (p<
the association was statistically non-significant. We 0.05) 10,other study done by El Zawahry et al diabetic
also analyzed the evaluated the risk of Body Mass status was significant risk factor for appearance of skin
Index as a risk factor for acrochordon. It was observed tags ( p< 0.001), similar to the findings of our study.11
that participants with overweight and obesity were at
Our study demonstrated the prevalence and
increased risk for developing skin tags compared to
association of skin tags with certain systemic conditions.
participant with normal Body Mass Index. However, the
Studies have demonstrated that multiple skin tags are
observed association was statistically non-significant. It
often associated with insulin resistance and obesity.
was observed that fasting blood sugar levels > 200mg/ 12,13
. Therefore obesity is a significant risk factor for
dl was a significant risk factor for the development of
development of skin tags. However, our study could
skin tags the association was not statistically significant
not demonstrate any significant association between
(P > 0.005) we also evaluated the association between
obesity and skin tags. The reason for this difference
skin tags and the presences of known history of diabetes
could be because of the innate characteristic differences
mellitus or hypertension or cardiovascular diseases.
in the participants who visited the outpatient department.
It was observed that known history of cardiovascular
However, our study demonstrates the significant
diseases was a risk factor and it increased with
relationship between history of cardiovascular diseases,
prevalence of skin tags (75.0%) compared to patients
hypercholesterolemia, and the presence of skin tags,
without history of cardiovascular diseases (12.3%). which has been substantiated by several other studies.
The observed difference was statistically significant (p<
0.001). Known history of hypertension was significantly
Conclusion
associated with the occurrence of skin tags. Participants
with known history of hypertension had increased the Our study demonstrated statistically significant
prevalence of skin tags (29.6%) compared to participants results with uncontrolled diabetes mellitus. Our
study elucidated the clinical pattern of presentation International Journal of Scientific and Research
of acrochordons and their association with potential Publications 2014;4(12):1-5.
risk factors. While diabetes mellitus, hypertension and
5. Phiske MM. An approach to acanthosis nigricans.
cardiovascular diseases were definitive risk factors,
Indian Dermatol Online J 2014;5(3):239-249.
our study could not demonstrate significant association
between obesity and acrochordons. This could be 6. Thappa DM. Skin tags as markers of diabetes
because of the innate differences in the sampling mellitus: an epidemiological study in India. J
characteristics present among the study participants. Our Dermatol 1995; 22: 729-731.
study may be taken as the basis for using acrochordons
7. Urschitz J, Urban Z, Granda C, Souza KA, Lupp
as an effective screening tool for several non-
C, Csiszar K et al. A serial analysis of gene
communicable diseases like diabetes mellitus,
expression in sun damaged human skin. Journal
hypertension, cardiovascular diseases and uncontrolled
of Investigative Dermatology 2002;119(1):3-13.
diabetes.
8. Shrestha P, Poudyal Y, Rajbhandari SL.
Ethical Clearance: Obtained from Institutional Ethical Acrochordons and diabetes mellitus: a case
committee. control study.NJDVL 2015;13(1):32-37
Source of Funding: Self 9. Maluki AH, Abdullah AA. Metabolic association of
skin tags. Int J Dermatol Clin Res 2016;2(1):3-11.
Conflict of Interest: Nil
10. ElSafoury O, Fawzi M, Abdel Hay RM, Hassan
AS, El Maadawi Z, Rashed L. Increased tissue
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Cholesterol in Adults (Adult Treatment Panel diabetes mellitus type 2 in Jabir Abu Eliz Diabetic
III) final report. National Cholesterol Education Center. American Journal of Dermatology and
Program (NCEP) Expert Panel on Detection, Venereology 2017; 6(3):41-50.
Evaluation, and Treatment of High Blood
13. Austin MA, King MC, Vranizan KM, Krauss RM.
Cholesterol in Adults (Adult Treatment Panel III).
Atherogenic lipoprotein phenotype. A proposed
Circulation. 2002; 17; 106(25):3143-421
genetic marker for coronary heart disease risk.
4. Narahari P, Rao PNS, Sharma N, Navukkarasu Circulation. 1990; 82: 495-506.
S, Navaneeth A, Om Prakash M. Predictors of
overweight and obesity among medical
students.
DOI Number: 10.5958/0976-5506.2019.01565.1

The Logical Investigation of the Digitalization andits

Capacities, Particularly those Influencing Conduct in Human
Brain Research on Based on the Psychological Distress

Nandita Sikari1, K HariKrishnan2

1
Research Scholar, 2Associate Professor, VIT University, Chennai Campus, Tamil Nadu,
India

ABSTRACT
Digitalization is a part of portable banking and an administration, giving other financial associations that
empowers its customer to lead an extent of budgetary trades remotely using for instance, a phone or Tablet
using programming usually called “Applications” gave by a cash related establishment to the reason.
Portable Banking is generally accessible for 24x7 and 366 days onwards. Some money related foundations
have limitations on which records might be blamed through versatile saving money, and in addition a
farthest point of sum that can be executed. In one educational model compact keeping cash described by
flexible dealing with a record implies course of action and budgetary organizations with the help of
convenience of media transmission contraptions. The degree of offered organizations may join
workplaces to lead banks, securities trade and pay charge on the web, etc.

Keywords: Versatile Accounting, Versatile Brokerage, Portable Financial Information Services, Versatile
saving money applications, Plastic money transaction, Psychological distress

Jel Classification: B25, C81, F23,

F44.
Introduction z Notifications on record development.

The earliest flexible keeping cash organizations z Observing of Term store.

used Short Message Service. The administration known z Accessibility of credit explanations.
as short message service dealing with a record with the
showing of cutting edge cells with wireless application z Accessibility of card explanations.
convention, reinforce engaging the use of the compact z Correlative reserves and value explanations.
web in the year of 1999, the essential banks in Europe
started to offer m-banking of their customers. The time z Insurance Policy Managements.
of 2010 or before was as often as possible performed by 2. Trade:
short message service on the all-inclusive audit of
z Funds, trades exchange between client’s
business inquire about papers from world business
connection accounts.
association like Australia6. The key supportive precedents
conceivable in universe of m-banking are following, z Paying outsiders including charge
with the incident to improvement and expanding installments of duties, web based shopping,
utilization of front line phones and tablet based book lodgings, tickets and so on.
contraptions, the utilization of adaptable putting aside
z Outsider store exchange. Bank Check remote
additional money esteem would empower client
stores.
accomplice crosswise over whole client life circle much
broadly than in advance. Minimal Banking associations z Cancelling an administration ask.
relate with
z Checking the status of administration ask.
1. Record Information: z Changing passwords.
z Mini proclamations and knowing of record
history.
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 211

3. Ventures: Digital Assistance (PDA’s). Wireless Application

z Mutual funds, Shares statements. Protocol goals are encouraged on web servers
and use an unclear transmission tradition from
z Wealth Management Services. destinations that is Hypertext Transport Protocol
z Notification alarms and warnings on security. (http). The most basic complexity among web and
website is the application condition.
4. Support:
II. SMS BANKING (Short Message Service):
z Status of demand for credit, debit cards
SMS permits instant messages normally up to
including contract endorsement and
one hundred and sixty characters to be sent to
protection scope with security.
and from portable cordless cell phone by means
z Check status of cheque-book and requesting of spared and forward framework. Around five
for PIN change, activation, chip-based cards hundred billions SMS were sent in 2001. Despite
etc. the fact that ninety five percent of this depends
z Exchange of information message and email on individual to individual correspondence and
including objection accommodation and phone message, different administrations, for
following of banking online requirement. example, e-keeping money are developing in
z Searching of ATM Locations. prevalence.

5. Content Services: z Verifying the status and changes of their

record.
z Common data, for example, weather
notification, news and so forth. z Verifying the status of the check mobile
numbers.
z Earn loyalty related offers through online
transactions. z Resettle the subsidize starting with one record
then onto the next.
z Search Location of bank branches and
ATM’s. z View the last trade made.
According to the US Federal Reserve report z Request trade articulation.
discovered sixty eight percent of cell phone proprietors
z Pay service charges.
had utilized versatile managing an account over the most
recent a year, in light of the study directed by Forrester, z Changes secret personal index numbers.
portable saving money will be alluring for the most part
III. Other Platforms: Different stages are accessible
to the more youthful more “well informed” client
or have been proposed for online banking
fragment.
experience. These incorporate the internet mode
Platforms of Cashless Banking: The essential use of stage in Japan, which had amazing around ninety
cashless banking was arranged in Finland. On 1992 as four percent supporters in 2015. Commission
on schedule, customers of European banks could make on membership gives docomo, internet mode’s
charge portions and records status, alter using a cell patent organization with yearly incomes of more
phone. Significantly all the more beginning late flexible than $13400 million every year2. Aside from
money related applications have depended upon the remote m-banking various thoughts exist for Point
improvement of some key gauges for remote electronic
of Sale applications, for instance utilizing short
associations and extended to in general markets. With
range remote innovation or network facilities in
everything considered, the stages utilized have been the
telephones and networks, for example, Bluetooth,
Wireless Application Protocol and Short Message
Service. clients can’t pay charges by associating with the
shipper’s point of sale terminal by a thing from
I. WAP BANKING (Wireless Application the candy machine pay a stopping meter and
Protocol): Wireless Application Protocol is a
numerous different applications4.
typical dimension for taking online substance and
impelled regard added organizations to remote
contraptions, for instance, phones and Personal
212 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
Part of Mobile-Banking in Customer’s as well as z Minimum balance notifications and so on can
Service Provider’s Point of View: Portable saving be gotten to from your convenient.
money from the client’s perspective, the client needs to
iv. Fund transactions in a split second to another
get to data, merchandise and enterprises in whenever on
record in a similar bank utilizing portable
his or her cell phone. Individuals can utilize their cell
managing an account.
phone to buy tickets for occasions or open transports,
pay for stopping, downloading substance and even cash v. Secure Banking.
exchange through portable included8. These are: vi. Mobile application innovation accompanies
z Mobile ticket propelled encryption advancements making it
protected and secure as Internet Banking.
z Mobile cash exchange
Demerits of Cashless Banking:
z Bill installments
z Making most extreme advantage of versatile
z Online any sort of records opening
keeping money one ought to have advanced mobile
z Balance checks phone. A few banks have particular programming
for particular portable, for example, I-telephone
z Tax installments
and Blackberry individuals ought to download
z Recharge and so forth. distinctive applications in view of the advanced cell
they possess5.
Portable managing an account from the specialist
organization’s perspective, in PDA versatile biometrics z Many specialists trust that versatile managing an
has acquired another measurement to putting money on account is all the more anchoring then web saving
the go. The PDA has changed the market for biometrics money as not very many infection or Trojans can
in the portable saving money. The times of booth - exist in telephone. In any case, that does not imply
based, secret word empowered exchanges will before that they are safe to any sort of dangers7.
long be a relic of times gone by. The in-assemble z There are likewise exceptionally constrained
advanced cell cameras, fingerprints sensors, receivers hostile to - infection programming alternatives for
currently let clients utilize their own equipment to catch cell phones. Individuals are less watchful with their
their facial, unique mark and voice qualities, making portable contrasted with PC. You should likewise
ready for what we call “multi-factor” biometrics . 1
refresh your hostile to infection on the portable in
Biometric is keeping money as expression paint with the event that you are an incessant client of
enhancements in innovation on a regular schedule, versatile saving money.
making it a to a great degree convincing alternative for
Worldwide Scenario of Cashless Banking in Recent
the two banks and their customers3.
Trends: Data on e-exchange of cash are uncommon
Portable Banking: Advantage and Disadvantage: and differentiates in definitions make cross-country tests
Favorable circumstances of Mobile Banking: troublesome, an essential examination by Nsouli and
Schechter (2002) from universal financial store exhibits
i. Anytime Banking. that online exchange of cash is particularly in all cases in
ii. Mobile Banking is Free. Austria, Korea, the Scandinavian countries like
Singapore, Spain, and Switzerland, where in excess of
iii. Various saving money administrations gave seventy five for each penny of all banks offer such
incorporate organizations.
z Information about account balancing,
Indian Scenario of Mobile Banking in Recent
z Credit/Debit card notifications, Trends: According to Hawkins (2002), in India, there is
z Payment of bills, recharge notifications. a danger of the rise of a ‘computerized isolate’ as the
poor are avoided from the utilization of the web thus
z Transactions details. from the budgetary framework. Observational proof
z Fund Transfer Facility (FTF), demonstrates that more extravagant nations have higher
convergences of web clients (higher than pay focus) in
examination with poorer nations.
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 213

Difficulties in Cashless Banking for Developing REFFERENCE

Countries: UNCTAD, 2002 data has stated couple
1. ACFE, Fraud Examiners Manual, Association of
of problems that makes country, when all is said in
Certified Fraud Examiners, Austin, TX, 2007.
done, are relied upon to defeat to fulfill the favorable
circumstances that electronic-money activities can 2. Ahmed ZU, Ismail I, Sadiq Sohail M, Tabsh
achieve the capacity to embrace worldwide innovation I, Alias H, Malaysian consumers’ credit card
to neighborhood necessities and the volume to fortify behavior, Asia Pacific Journal of Marketing and
open help for e-back. Logistics, 2001, 22(4), pp 528-544.
3. Barker KJ, D’Amato J, Sheridon P, Credit card
Conclusion fraud: awareness and prevention, Journal of
financial crime, 2002, 15(4), 398-410.
The outcomes introduced in this paper, speak to
the network of research which has been the principle 4. Hasan SA, Subhani MI, Osman M, Plastic Money/
enthusiasm of creators as of late and which is Credit Cards Charisma for Now and Then (A Thin
coordinated towards finding ideal conditions for Line between Easy Money and Risky Money),
utilizing the capability of the versatile communication or European Journal of Scientific Research, 2011,
portable saving money universally and the specialized 62(1), 123-127.
security identified with the advancements, yet in 5. Mary LS, Wisconsin Community Banking News,
addition with the client trust, protection and security as Going Mobile- Assessing the Pros/Cons of
far as social experience. Current individuals even in Mobile Banking, 2011.
dream likewise they thing about innovation, consider
6. Patil S, Impact of plastic money on banking trends
present day keeping money that is called “Portable
in India, International Journal of Management
Banking”.
Research and Business Strategy, 2014, 3(1).
Conflict of Interest: Exceptionally in India, people are 7. Dr. Uppal RK, Transformation in banks in a
progressively beneficial to use liquid cash and there is highly competitive E-Age through E-services
no obligation to advance check in future for seeming – An Empirical study, Indian journal of
complete national yield. Management,
2014, Vol-4, 17-30.
Ethical Clearence: Nil
8. Sumi FR, Safiullah AB, Problems and Prospects
Source of Funding: Self from related review of Plastic Money in Bangladesh, IOSR Journal of
articles, Business and Management, 2014, 16(12), 31-38.
reports.
DOI Number: 10.5958/0976-5506.2019.01566.3

To Study Behavioral and Socio Economic Factors of Non

Communicable Diseases in Northeast India Using NFHS-4

Phrangstone Khongji
Assistant Professor in Statistics, Department of Basic Sciences and Social Sciences,
North Eastern Hill University, Shillong, Meghalaya

ABSTRACT
Introduction: This paper investigates the incidence of non-communicable diseases(NCDs) in North-
Eastern
states of India using NFHS-4 data and correlates with the different proximate and the secondary risk
factors.
Method: Descriptive statistics were initially undertaken to understand the incidence of non-communicable
diseases with the different proximate and the secondary risk factors. To finally draw statistically inference,
logistic regression model was applied to determine the significance and nature of relationship between the
predictor and the covariates.
Results: The result reveals that ‘age’ is a significant factor for both women and men under study in
determining the prevalence of non-communicable diseases under study. The findings also shows that among
the surveyed population, rural women and men are having high chances of NCDs compare to urban
counterparts.
Conclusion: In Northeast, much research is needed to be undertaken for planning on time effective NCD
surveillance, to identify the major risk factors and the cost.

Keywords. Non Communicable Diseases, North east India, Logistic regression, Nutritional Index, Wealth
Index.

JEL classification codes: I100,

I120
Introduction Therefore, this study will try to address these lacunae
in providing information on the various socio economic
Many studies have identified Non-Communicable
and demographic risk factors associated with some
Diseases (NCD) as increasingly predominant diseases in
non-communicable diseases by the used of the recently
many regions.
available data and information from National family
Multi-centre studies have been initiated by the health survey 4.
ICMR to find out the genetic factors, in addition to
common environmental exposures, tobacco smoking, Review of Literature
alcohol consumption etc, which could possibly explain
the high prevalence of certain Non-Communicable Current Health Scenario in Rural India, as reveals
Diseases (NCD) in Northeast India. by Patil(1), that the country is passing through a phase of
double health burden of high incidences of
Not many literatures have focused about the Non- communicable diseases and an increasing trend of
communicable diseases especially in the North-East. NCDs.

Saxena, et al (2) emphasize that identifying risk

factors of non-communicable diseases in rural settings
Corresponding Author: Department of Basic Sciences and Social Sciences North
Dr Phrangstone Khongji Eastern Hill University, Shillong, Meghalaya Email:
Assistant Professor in Statistics [email protected]
occupies a central place in the surveillance system
because of the importance of the lag time between
exposure and disease.

The need of surveillance and procurement

of
details regarding NCD risk factors is
essential for
215 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 215

health programs/policy planning and implementation, Methodology for Analysis

particularly in a country like India with a rapidly
increasing burden of NCDs(3). The study used both MS Excel as well as Statistical
Package for Social Sciences (SPSS) for data analysis.
Multi-morbidity among older adults in India as SPSS was used for cross tabulation to present
reveals by Mini and Thankappan(4) found that more relationships between different variables. Logistic
than 30% had multi-morbidity. Older age, women, regression which is used to predict the risk of
those in higher socioeconomic status, tobacco users and developing a given diseases (e.g. diabetes, asthma,
alcohol users were more likely to have multi-morbidity thyroid and hearth diseases) based on the observed
compared to those with no NCD. characteristics of the respondent (i.e. age, residence,
wealth status, occupation and educational
Research Objective attainment).

The objective of the present study focuses We have also considered some behavioral or
on investigating the determinants on some Non- proximate risk factors of the selected non-communicable
Communicable diseases through various behavioral and diseases which are collected during NFHS-4; two of
socio economic and demographic risk factors in states of these factors are smoking and drinking. We also
Northeast India using NFHS - 4. constructed the third proximate factor called the
Nutritional Index. This index is to determine the
nutritional status of the surveyed population and was
Sources of Data
constructed using the Principal Component Analysis
The National Family Health Survey 2015-16 (PCA) in SPSS, base on the following variables: (1)
(NFHS-4)(5), the fourth in the NFHS series, provides intakes milk or curd (2) intakes pulses or beans (3)
information on population, health and nutrition for India intakes dark green leafy vegetables (4) intakes fruits (5)
and each State/Union territory. NFHS-4, for the first intakes eggs (6) intakes fish (7) intakes chicken or meat
time, provides district-level estimates for many (8) intakes fried food (9) intakes aerated drinks. We have
important indicators. The Ministry of Health and Family divided this index into the three ranges they are: Low
Welfare, Government of India designated International Range, Medium Range and High Range where low range
Institute for Population Sciences, Mumbai as the nodal implies low status of nutrition.
agency to conduct NFHS-4. Four Survey Schedules - Data Interpretation: Among the various non-
Household, Woman’s, Man’s and Biomarker - were communicable diseases, data only on the Diabetes,
canvassed in local language using Computer Assisted Asthma, Thyroid, Heart Diseases and Cancer are
Personal Interviewing (CAPI). NFHS-4 fieldwork for available in NFHS-4.
India was conducted from January 2015 to December
2016 and gathered information from 601,509
Table 1: Number of women and men interviewed in
households, 699,686 women, and 112,122 men.
NFHS 4 by states of Northeast India
As our study will be concentrated in states of Number
Northeast, India by the use of NFHS-4 in connection Number Men
States Women
with the topic of this research. Hence, the following interviewed
interviewed
tables provide an overview of the sample size collected Arunachal Pradesh 14294 2140
during the survey for the 8 different states. Assam 28447 4191
The data provide information on various non- Manipur 13593 1886
communicable diseases like Diabetes, Asthma, Meghalaya 9202 1236
Thyroid, Heart Diseases and Cancer which will be Mizoram 12279 1749
used in the present study. Information’s on the various Nagaland 10790 1596
socio-economic risk factors on the above mention Sikkim 5293 879
NCD’s is obtained from the data. Tripura 4804 878
Total 98702 14555
Source: NFHS 4
Interpretation of Data based on secondary risk are considered in the present study are age, alcohol
factors: Some of the secondary risk factors considered consumption, smoking and Nutritional Index. These are
in the present study are Sex, Residences, Educational considered as proximate for the fact that these factors
Attainment, Occupation and Wealth Index. These are may directly led to incidences of NCDs viz., diabetes,
considered as secondary for the fact that these factors asthma, thyroid, cancer and heart diseases.
may indirectly led to incidences of NCDs viz., diabetes,
asthma, thyroid, cancer and heart diseases. Diabetes by the proximate risk factor depicts that in
all states and among those who have the disease, highest
The frequency distribution of the above mentioned proportion belong to medium range of the nutritional
NCDs by the secondary risk factors reveals that among index both for the men and women, age group of 40+ for
people who suffer from the stated NCDs, a greater both men and women.
proportion of them are Christian from Arunachal
In general it is observed that, with increase in age
Pradesh, Meghalaya, Mizoram and Nagaland whereas
the occurrence of the disease seems more prominent
in the state of Assam, Manipur, Sikkim and Tripura,
especially in the states of Assam, Mizoram and Tripura.
incidences of NCDs is higher among Hindus.
Among samples having Heart Diseases these, highest
Many literatures reveal that risk factors may be
proportion of them belongs to medium range of the
affected by lifestyle choices that are often influenced by
nutritional index both for the men and women. With age,
economic development and urban living. The data also
the incidence of the disease seems to increases and this
depicted that among people who suffer from the stated
trend become more pronounce from the age 30+ in all
NCDs, there are more proportion of rural people having
states except in the state of Meghalaya, were the disease
the diseases compared to their urban counterparts in is prominent even among younger age group of women.
almost all the states.
Interpretation Binary Logistic regression for women:
The data in the present study reveals that incidences All the risk factors are categorize into various classes,
of diabetes is more for people with the middle and richer the cross tabulation shows the distribution of NCDs by
wealth index groups except for the state of Tripura Age Group, Residences, Wealth, Educational status and
where the chances of having the diseases is more with Occupational status and also by some of the proximate
people of the poorer wealth index level. risk factors as Nutrition, Smoking and Drinking
Alcohol.
In the case of Asthma incidences is highest for
‘middle wealth index’ groups in the states of Arunachal In order to statistically verify the nature and
Pradesh, Meghalaya and Sikkim whereas the incidences strength of the associations between the above
of the disease is high with the ‘poorer wealth index’ mentioned NCDs with the risk factors, a binary
people in the states of Assam, Nagaland and Tripura. logistic regression model is applied, whereby the
risk factors constitute the independent variables and the
In connection with occupation, the data reveals corresponding NCDs on the depending variable. The
that from among people who have NCDs viz., diabetes, model when applied by state does not yield significant
asthma, thyroid, heart diseases and cancer incidences a result which may be due to the small number of samples
significant proportion of them belong to those groups of of the incidences of the Diseases. Hence the model is on
people who work in agricultural sector. the combine data of North east and the outcome of the
model is discussed below.A logistic regression on
Thyroid can be seen is high with women of urban
women with the above mentioned explanatory
residence in the state of Mizoram, Nagaland, Sikkim and
variables and each of the corresponding NCDs.
Tripura. Heart diseases are found out to be high with the
people of rural residence in almost all the states of North The model with Diabetes as the dependent variable
East. However, in the some states we have found that which is categories as yes or no, reveals that age is
people of urban residence are also suffering the most. one factor that can have significantly determine the
risk of incidence and the Table 2 reveals that at less
Interpretation of Data based on
than 0.01 level of significance, the increase in age of
proximate(behavioral)
the respondent is associated with increased odds of the
risk factors: Some of the proximate risk factors
that diabetes diseases.
Table 2: Binary Logistic regression of NCDs with the corresponding risk factors for women
Diabetes Asthma Thyroid Heart Diseases Cancer
Women
Odds ratio Odds ratio Odds ratio Odds ratio Odds ratio
Age 1.097* 1.027* 1.039* 1.046* 1.055*
Religion
Buddhist/Neo-BuddhistR
Hindu 1.412** 1.434** 2.395** 1.448* 2.118
Muslim 2.493* 1.535** 2.845** 1.755* 4.701**
Christian 1.125 1.856* 1.932** 2.362* 5.087**
Residence
RuralR
Urban 1.121 .944 1.083 .969 .826
Wealth Index
RichestR
Richer .831** .877 .803* 1.028 1.076
Middle .590* .928 .672* 1.090 .803
Poorer .341* .935 .656* 1.006 .888
Poorest .243* .640* .496* .785** .542
Educational Attainment
No EducationR
Incomplete Primary .957 1.240 .643* 1.034 1.614
Complete Primary 1.163 1.231 .588* 1.179 1.203
Incomplete Secondary 1.351 1.245 .745** 1.342** .781
Complete Secondary 1.232 1.265** .851** 1.325* 1.878
Higher 1.158 1.345** .925 1.277** 2.170
Drink Alcohol
NoR
Yes .982 .751* 1.456* 1.035 .488*
Smokes Cigarette
NoR
Yes .887 .721** .822 .619* .401**
Nutrition status
High RangeR
Medium Range .897 .879** .856* .866* .570*
Low Range 1.473** .650** .530* .968 .685
Constant .001 .008 .004 .004 .000
Source: Authors own calculation. *p < 0.01, ** p < 0.05

In connection to nutritional status, the model depicts The outcome of the regression model as depicted
that among those who have the diabetes, the odd of the in the table shows that age is again a highly significant
disease is 1.5 times to people who belongs to the low (i.e. p<.000) factor with women who is currently having
range compare to the people who belongs to the high
the thyroid diseases.. Wealth is another significant
range group.
factor (p <0.01) in this case in determining the odds of
As in the case of Diabetes, the Table 2 of the incidences, whereby the odds of women who belongs
logistic model shows that increase in age is associated the poorest, poorer, middle and richer wealth index are
with increased odds of the Asthma diseases. less comparing to the people with the richest wealth
index.
The regression model further depicts that women The table 2 shows that drinking alcohol increases
who have attended school have less odds of having the the chances of the disease. Further women in the highest
nutritional group have higher odds of having the disease
thyroid diseases, although internal variation(between
compare to middle nutritional group and low nutritional
educational status) of the incidences of the diseases group.
prevail. Among the proximate risk factors, the table
Age is an important factor determining the
shows that the odds of having the disease among
incidences of cancer among women in the reproductive
drinking women are 1.5 higher than those who does not age group. Further women in the highest nutritional
drink. group have higher odds of having the disease compare
to middle nutritional group and low nutritional group.
As in the other previously mentioned NCDs, age is
Logistic regression on men with the above
a significant factor in the case of heart diseases also as
mentioned explanatory variables and each of the
depicted in the table 2, showing that an increase in age is corresponding NCDs is depicted in Table 3.
associated with increased risk of the disease.

Table 3: Binary Logistic regression of NCDs with the corresponding risk factors for men
Diabetes Asthma Thyroid Heart Diseases
Men
Odds ratio Odds ratio Odds ratio Odds ratio
Age 1.080* 1.030* 1.057* 1.070*
Religion
Buddhist/Neo-BuddhistR
Hindu 1.407 .611 2.237 1.495
Muslim 1.283 1.345 3.672 1.090
Christian 1.936 1.022 5.342 1.642
Residence
RuralR
Urban .569* 1.536 1.009 .979
Wealth Index
RichestR
Richer .736 .593 1.764 .705
Middle .614** .732 2.604 .692
Poorer .491* .523 2.691 1.117
Poorest .378* .452 2.375 .985
Educational Attainment
No EducationR
Incomplete Primary .483** 2.706 .475 .739
Complete Primary .465** 2.964** .257** .619
Incomplete Secondary .215* 2.628 .259 .858
Complete Secondary .502* 2.302 .526 .822
Higher .781 1.246 .355** .908
Drink Alcohol
NoR
Yes 1.396** 1.173 .977 .962
Smokes Cigarette
NoR
Yes 1.075 1.714** 1.119 .687**
Conted…
Occupation
Not Working/No OccupationR
Professional/technical/managerial 1.517 1.051 2.295 .989
Clerical 1.219 1.057 1.420 1.064
Sales 1.575 .913 1.498 .715
Agricultural 1.908** .997 1.203 1.311
Services .966 .995 1.065 .829
Skilled& Unskilled manual 2.431* .289** 1.494 .720
Nutrition status
High RangeR
Medium Range .477* 1.079 .384* .620**
Low Range .657 .479 .441 1.535
Constant .002 .001 .000 .002
Source. Authors own calculation. *p < 0.01, ** p < 0.05
Limitation of the Study: The first limitation is that the government and policy makers should ensure higher
study was conducted with a limited sample size for men education for the masses.
comparing to women and hence many of the risk factors As we have seen in this study that people who work
for men were found not to be statistically significant and in agricultural sectors have more chances of having
hence would act as a limitation. NCDs compare to people from other occupation. Thus,
The second limitation of the study is the problem of government should take the initiative of ensuring that
identifying the various risk factors. If the more data more awareness of health lifestyle be provided to people
could be collected on biomedical report of those who work in agricultural sectors.
respondents who is currently suffering from the
following diseases i.e. diabetes, asthma, hearth diseases, Conflict of Interest: None
thyroid and cancer than the various risk factors for Source of Funding: Self
causing the diseases would be more clearer.
Scope of the further study: Since this study has been Ethical Clearance: Not applicable
compiled at all the state level of Northeast. Therefore,
further we can extend this work to the district level also REFERENCES
for all the states of the Northeast.
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This study can further be complimented with Health Scenario in Rural India, Australian Journal
primary data collected from the various sources like of Rural Health. 2002, 10(2):129-135.
hospitals, dispensaries, than the major risk factors which 2. Saxena A, Kandpal SD, Goel D, Bansal S.
causes the NCDs could identified appropriately. Prevalence of risk-factors of non-communicable
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by taking the data from the NFHS-4 for finding out the Community Health, 2011 23(2):65-68.
issues of adult health which are cause by the different 3. Nethan S, Sinha D and Mehrotra R. Non
modifiable risk factors due to the common non- Communicable Disease Risk Factors and their
communicable diseases in Northeastern states of India. Trends in India. Asian Pac J Cancer Prev,
A few suggestions towards policy recommendations of 18(7): 2005-2010.
the study are as follows 4. Mini GK and Thankappan KR. Pattern, correlates
Since in our study we mostly found that people of rural and implications of Non-communicable disease
residence are suffering from the diseases, therefore multimorbidity among older adults in selected
better
diagnostic facilities should be provided in Rural areas. Indian states: a cross-sectional study, BMJ Open,
2017 7:1-6.
In the present study we found that people with
incomplete secondary education have higher chances 5. International Institute for Population Sciences.
of having NCDs. This suggests that higher educational National Family Health Survey 2015-16, Mumbai:
level reduces the risk of NCDs. Thus, in this connection 2017.
DOI Number: 10.5958/0976-5506.2019.01567.5

A Study to Assess the Knowledge and Self Reported Practices

Regarding Care of Arterio Venous Fistula among Patients at
Selected Haemodialysis Units of Sangli City

Pratik N Amrao1, Swati C. Kurane2

1
M.Sc Nursing, 2Clinical Instructor, Bharati Vidyapeeth (Deemed to be University) College of Nursing,
Sangli

ABSRACT
“A study to assess the knowledge and self reported practices regarding care of arteriovenous fistula
among patients at selected haemodialysis units of sangli city”. Background: A.V.Fistula is referred as
gold standard method to carry out the dialysis of client, so the care and appropriate knowledge is most
important factor for smooth access. Objectives: 1. To assses the existing knowledge regarding A.V.Fistula
care among haemodialysis patients. 2. To assess the self reported practices regarding care of A.V.Fistula
among haemodialysis patients. Methodology: A present study was conducted by using quantitative
approach with non-experimental descriptive research design. Nola j penders health promotion model was
used which is revised in 1996for conceptual framework. Proposal with tool presented in front of ethical
committee for permission. Total 100 samples were selected by Probability simple random sampling
method. Data collection tool had knowledge questions to assess knowledge and practice were assessed by
using likhert scale. Result and conclusion: knowledge scores, 84.00% subjects were having average
knowledge, 16% were having poor knowledge and no one in the good knowledge category. In the present
study of patients of A. V. fistula, in Practice scores, 37% of subjects identified with inadequate practice
score 63% identified with appropriate practice score.Implementation of knowledge regarding A.V. Fistula
care and its practices would be beneficial to the patients who are going under haemodialysis treatment for
increasing the patency and reducing the complications of A.V.Fistula for reducing the life threatening
conditions.

Keywords: A.V.Fistula, knowledge, self reported

practices
Introduction disease and reeferd vascular access problems, which
includes failure to mature of A.V. Fistula and placement.
National vascular access initiative conducted the
Education helps the patients to live best quality of life.
physical examination of Arteriovenous fistula in 4
It increases the self confidence of patients to carry out
weeks to identify the failure and other complications
the necessary behaviour to achieve the goal. Self care of
and recommend it to diagnostic evaluation. For proper
A.V.Fistula will help the patient for better management
identification of the problems related to A.V.Fistula
of vascular access. To promote the knowledge and
standard protocols were obtained as monitoring, timely
practice on care of A.V.Fistula by giving brouchers.
check up, education to all care givers as well as patiens
Hence study is needed to this population and this
to improve the vascular patency( e.g., application of
period2. proper education regarding care of A.V.
adequate pressure on vascular site, brouchers)1. Self
Fistula among patient and relatives should be
management throughout the levels of chronic kidney
provided. A list is present regarding care of A.V.
Fistula at home. Avoid sleeping at site, don’t lift up
the heavy objects, keep the area
clean, these guidelines provides information like how
Corresponding Author: to admire the sign and symptoms of complication. 3
Swati C. Kurane,
Clinical Instructor,
Materials and Method
Bharati Vidyapeeth (Deemed to be University)
College of Nursing, Sangli–416416 A present study was conducted by using quantitative
Email: [email protected] approach with non-experimental descriptive research
221 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 221

design. The conceptual framework was based on Nola The above table shows that, in Practice scores, 37%
J Penders health promotion model revised in 1996 of subjects were having inadequate practice and 63%
with individual characteristics, activities related effect, were having adequate practice. So it evident that more
commitment to plan of action and behavioural outcomes. efforts are needed to impliment to carryout appropriate
The reliability was done by using split half method practices. Knowledge category.
‘r’ was calculated by using Karl Pearson’s formula
coefficient‘r’ofthequestionnairewas0.9. Validity was Discussion
done from 20 experts..Proposal with tool presented in
This study revealed that 84% of patients were
front of ethical committee for permission. Total 100 having average knowledge about AVF care and 16%
samples were selected by Probability simple random were having poor knowledge. This results suggest
sampling method. Pilot study was conducted with 10 that proper implementation of knowledge regarding
samples and the study was found feasible. Final study AVF care and self-practise is needed to heamodialysis
conducted with same data collection tool. Data patients in appropriate manner, in Practice scores 37%
collection tool had knowledge questions to assess of subjects were having inadequate practice and 63%
knowledge and practice were assessed by using likehert were having adequate practice.. In our, the study also
scale. reveals the previous knowledge regarding AVF care
about 47% patients were having previous knowledge
Assumptions: Haemodialysis patients may have and 57% were having no knowledge about AVF care.
some This indicates that maximum number of patients lack in
knowledge regarding care of A.V. knowledge of AV Fistula care. So there is need of
Fistula. providing knowledge regarding AVF care. The study
also reveals that 74.42% patients got the information
about AVF care from articles, 18.60% patients from the
Results newspaper and 6.98% got the information from the
television.
Section 1: The analysis of data related to assessment of
the The study also reveals about the number of years on
knowledge regarding care of A.V. Fistula among dialysis treatment, it shows that 8% of the patients had
patients. A.V. Fistula since last one year, 30% patients had A.V.
Fistula since 2 years, 14% of patients have A.V. Fistula
Table 1: Frequency and percentage distribution of since 3 years and since last 4 years 29% had A.V. Fistula
knowledge score. and since last 15% had AV Fistula since last 5 years. So
n = 100 the study indicates that maximum of patients have AV
Fistula since 2 years as well as 4 years. Which indicates
Groups Frequency Percentage % that there is need of implementing education about
Poor (0-4) 16 16% A.V Fistula care and its importance to reduce the
Average (5-8) 84 84% complications and increase the compentancy of A.V.
Fistula.
The above table shows that in knowledge scores,
The result of our study suggested the need of
84.00% of subjects were having average knowledge,
introduction to A.V. Fistula care which help to improve
16% were having poor knowledge. the life style pattern of patients in long term. Appel et al
stated that intervention from healthcare providers makes
The analysis of data related to assessment of the self
good sense, to help patients reduces the controllable AV
reported practices regarding care of A.V. fistula among fistula failure through proper lifestyle choices.
patients.

Section 2: The analysis of data related to assessment of Conclusion

the self reported practices regarding care of A.V. Fistula This chapter gives brief description of study as
among patients. well as summary and the outcome of the study. It also
gives appropriate implications and recommendations for
Table 2: Frequency and percentage distribution of further research study.
Practice score.
n = 100 The main aim of the study was, to assess the
knowledge and self reported practices regarding care
Groups Frequency Percentage %
Inadequate (0-5) 37 37%
Adequate (6-10) 63 63%
of Arterio Venous fistula among patients at selected REFERENCES
haemodialysis units of Sangli city. The design used for
1. Mary TC, Edwin H, Fistula First Breakthrough
the study was non experimental descriptive research
Initiative Stratergic Plan Mid – Atlantic renal
design. The study was conducted at selected
coalition, Oklahoma 2009;4(2) : 12-6.
haemodialysis units of Sangli city. The Sample size of
the study was 100 patients of Arterio Venous fistula. 2. Steven W, Kimberly N, Christopher S.H.
increasing use of arterio venous fistula in
The reliability of the tool was determined Split Half haemodailysis: Economic benefits and economic
Method of Reliability, the tool was administered to 10 barriers john Hopkins Bloomberg school of public
samples. Reliability of the knowledge tool was found to health, Baltimore, Maryland 2007;2(7): 5-8.
be 0.90 and for the practice tool was 0.82. 3. Stewen MH. Increasing Arteriovenous Fistula in
The pilot study was conducted, to assess the Hemodialysis Patients: Problems and Solutions.
feasibility of the study and to decide the statistical Official Journal of ISN. 2007 Jul 15; 22(2): 522-
analysis and practicability of research. It was found 528.
feasible. 4. Black M Jacob E Medical Surgical Nursing
Clinical management for community care.7th Ed.
Finding of the present study revealed that significant USA: WB Saunders Company; 2004.
amount of patients were lacking the knowledge about
A.V. Fistula care and proper implementation of healthy 5. Smeller CS. Text book of medical surgical
lifestyle.. Planning for implementation of knowledge nursing.
regarding A.V. Fistuala care and its practices would 10 Ed. Philadelphia: Lippincott Williams and
th

be beneficial to the patients who are going under Wilkim; 2004.

haemodialysis treatment for increasing the patency and 6. Lewis, Heitkemper, Dirksen. Medical Surgical
reducing the complications of A.V.Fistula for reducing Nursing Assesment and management of clinical
the life threatening conditions. problems. 6th Ed. Missouri: Mosby Elseiver
publication; 2004.
Implimentation of knowledge and self care practices
7. Stewen MH. Increasing Arteriovenous Fistula in
would be beneficial to patients under haemodialysis
Hemodialysis Patients: Problems and Solutions.
treatment in many ways like it reduces the chances of
Official Journal of ISN. 2007 Jul 15; 22(2): 522-
A.V. Fistula failure,infection and any other severe life
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to lack of knowledge and practice regarding taking care 8. Derakhshanfar A, Gholyaf M, Niayesh A.
of it and its importance. Lifestyle pattern changes are Assessment of Frequency of Complications of
recommended to all patients on haemodialysis Arterio Venous Fistula in Patients on Dialysis.
treatement to reduce the risk factors and improve the Saudi J Kidney Dis Transpl. 2009 Jul 5; 20(5):872-
patency of A.V. Fistula car study was done in selected 75.
hospital on a limited population to generalize the 9. Mendelssohn DC. Ethier J. Assessment of
findings. Practice on Care of Fistula 2005. Available from
http:// www.ncbi.nlm.gov
Conflict of Interest: Column is Nil.
10. Mary TC, Edwin H, Fistula First Breakthrough
Source of Funding: Self. Initiative Stratergic Plan Mid – Atlantic renal
coalition, Oklahoma 2009;4(2) : 12-6.
Ethical Clearance: Proposal of research with the data
collection tool was presented in the front of research 11. Steven W, Kimberly N, Christopher S.H.
committee for approval prior permission from hospital increasing use of arterio venous fistula in
and haemodailysis unit were taken. Informed written haemodailysis: Economic benefits and economic
consent from each participant was taken. Which included barriers john Hopkins Bloomberg school of public
name, number, organization, time duration of health, Baltimore, Maryland 2007;2(7): 5-8.
participation, termination of participation, purpose of the 12. Literature Review: Writing Audio Duke
study, incentives, benefits, and where it was promised University. 2001. Available from http://uwp.aas.
that there will be no risk to the clients. Principle of duke.edu/wsstudio. (18)
confidentiality was attained by giving code number to 13. K/DOQI Clinical Practice Guidelines for Vascular
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14. Rehman R, Schmidt RJ, Moss AH. Ethical and
Legal Obligation to Avoid Long-Term Tunneled
Catheter Access. Clin J Am Soc Nephrol. 2009
Feb; 4(2):456-60.
DOI Number: 10.5958/0976-5506.2019.01568.7

A Study to Assess the Effectiveness of Topical Application of

Honey on LSCS Wound Healing among Postnatal Mothers
from Selected Maternity Hospitals of Sangli, Miraj and
Kupwad Corporation Area

Priti D Khade1, Archana Dhanawade2

1
M.Sc Nursing, 2Assistant Professor, Bharati Vidyapeeth (Deemed to be University) College of Nursing,
Sangli

ABSTRACT
The LSCS wound healing was evaluated by using reeda scale to find the LSCS wound healing status among
postnatal mothers who undergone LSCS. The intervention was exercised honey application on LSCS
wound among postnatal mothers, 5ml twice in a day for 6 days to the subjects of experimental group. The
reliability of the tool was determined by using inter-rater method on 10 samples with 6 days of interval. The
reliability coefficient “r” was calculated by using Karl Pearson’s coefficient formula, which was more than
0.7, hence the tool was found to be reliable.Also, the reputed and eminent 30 experts from the field
related to study had validated the tool for its content, Quasi experimental research study was conducted
during the month of August 2018 by selecting the 80 postnatal mothers 40 in each group of experimental
and control. The subjects were selected by using non probability purposive sampling technique. Analysis
was done using frequency and percentage distribution test.
Aim: To assess the condition of LSCS wound before application of honey &.To assess the effectiveness of
honey application on LSCS wound healing.
Keywords: Effectiveness, honey, L.S.C.S.wound, postnatal mothers
Introduction to the newborn or mother. Worldwide rise in LSCS
rate during the previous three decades, source of
Child birth is end of the pregnancy by one or more
alarm and request an in depth study. According to the
babies exit a women’s uterus by vaginal passage or
new studies from Oct 2017-2018 over the phase of six
LSCS. In 2012 about 23 million deliveries occurred
months emergency LSCS (72.1%) and primary LSCS
by a surgical method recognised as LSCS. 1 Ensuring
(66.5%) were added everday.The commonest sign for
secure pregnancy and maternity occupies a pivoted
LSCS was previous LSCS in 35% followed by foetal
responsibility and has been measured as one of the
distress, breech presentation, severe oligohydraminos
vital issues in the framework of reproductive and child
and pre eclampsia.3 Honey is a viscous, supersaturated
birth programme. Support from study research denotes
sugar solution derivates from nectar gathered and
that there is rise for LSCS deliveries chiefly during
customised by the honeybee and has been used since
complications confronted at the time of pregnancy and
prehistoric period as a remedy in wound care.4 Honey
delivery.2 Lower segment caesarean section is optional
is non stained low price substance to be made up of
when vaginal delivery pose a possibility create
CHO, water, pollens organic composite, enzymes and
hazard
amino acid pigments having antibacterial and opposed
to provocative skin texture.5 The honey works on the
body immunity. Honey thousands of years used to be
Corresponding Author: concerned with innumerable harms like wounds and
Archana Dhanawade burns.6. It gives quick removal of damaged tissues and
Assistant Professor disinfects the wounds, and stimulated progress of wound
Bharati Vidyapeeth (Deemed to be university) tissues as a result of quick curative and initiates the
College of Nursing, Sangli-416416
224 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 224

remedial course of action in resting wounds. Its rapidly wound healing in selected maternity hospitals. 80
decreases the pain.8 The difference in local antiseptic samples are choosed by using non-probability purposive
solution and honey on the wound after the surgery sampling method. In experimental group, the wound
showing the using applying of honey giving the fast dressing done by using honey, in control group simple
result of wound healing; lessen hospital stay, size of the dressing was used. A standardized REEDASCALE was
scar and the necessity for antibiotics. used to assess the effect of honey application on LSCS
wound. The study adopted modified Imogene king’s
Objectives goal attainment model for developing the conceptual
framework of present study. Analysis was done using
1. To assess the condition of LSCS wound
before frequency and percentage distribution and‘t’ test.
application of honey.
Hypothesis:
2. To assess the effectiveness of honey
application H0: There is no effect of application of honey on
on LSCS wound healing. L.S.C.S.
wound healing.

Material and Method H1: There is effect of application of honey on L.S.C.S.

wound healing.
Quasi- experimental two group pre-test post-test
design was directed to assess effect of honey on
LSCS

Findings
Section I
Table I: Frequency and Percentage Distribution of Demographic Variables
(n = 40 + n = 40)
225 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, 225
July 2019, Vol.10, No. 7
Sr. Experimental Control
Variable
No. Frequency Percentage Frequency Percentage
Below 20yrs 3 7.50 2 5.00
21-25yrs 19 47.50 20 50.00
1 Age in years
26-30yrs 17 42.50 17 42.50
above 30yrs 1 2.50 1 2.50
Primi 17 42.50 20 50.00
2 Gravida
Multi 23 57.50 20 50.00
Mixed 22 55.00 22 55.00
3 Diet Pattern
Veg 18 45.00 18 45.00
up to Rs. 10000 5 12.50 3 7.50
4 Income Rs.10001-20000 28 70.00 26 65.00
Rs.20001-30000 7 17.50 11 27.50
46-55kg 12 30.00 11 27.50
5 Weight 56-65kg 19 47.50 28 70.00
66-75kg 9 22.50 1 2.50
1. AGE: According to the age in the stud y, 2. GRAVIDA: According to the Gravida in the
highest number of samples i.e.47.50% are from study, highest numbers of samples i.e. 57.50%
experimental group belongs to age group of 21-25 from Experimental group are multigravida
yrs. Whereas 50% are from control group belongs whereas 50% samples from control group are
to age group of 21-25 years. Primi.
3. DIET: According to the diet in the study, highest per month whereas 65% samples from control group
numbers of samples i.e.55% from experimental having 10001-20000 income per month.
group are having mixed diet whereas 55%
5. WEIGHT: According to the weight in the study,
samples from control group having mixed diet.
maximum numbers of the samples i.e.47.50% from
4. INCOME: According to the income in the study, experimental group having 56-65kg weight whereas
maximum numbers of samples i.e.70% from 70% samples from control group having 56-65kg.
experimental group are having 10001-20000
income

Section II

Table 2: Condition of LSCS Wound Healing between Experimental and Control Group
(n = 40 + n = 40)

Experimental Group
Group Frequency Mean S.D. t value P value
Day 1 40 12.65 0.89
43.91 0.000
Day 6 40 4.45 0.87
Control Group
Group Frequency Mean S.D. t value P value
Day 1 40 12.40 0.90
25.85 0.000
Day 6 40 8.32 1.07

Above table shows that the comparison of the LSCS wound healing score of the day 1 and day 6 of experimental
and control group was done by the paired t test.

In experimental group day 1 score was 12.65 with SD of 0.89 and day 6 score was 4.45 with SD 0.87. The value
of the paired t test was 43.91 with p value 0.000.

In control group day 1 score was 12.40 with SD 0.90 and day 6 score was 8.32 with SD 1.07.The value of the
paired t test was 25.85 with p value 0.000.shows that there was significant difference in the average LSCS wound
healing score, at 5% level of significant.
Section III

Table 3: Assessment of the Condition of L.S.C.S. Wound Healin before and After Application of Honey
(n = 40 + n = 40)
Experimental Group Day 1 Day 6
Healing Score Frequency Percentage Frequency Percentage
Good 0-5 0 0.00 37 92.50
Medium 6-10. 0 0.00 3 7.50
Raw 11-15. 40 100.00 0 0.00

Control Group Day 1 Day 6

Healing Score Frequency Percentage Frequency Percentage
Good 0-5 0 0.00 0 0.00
Medium 6-10. 0 0.00 39 97.50
Raw 11-15. 40 100.00 1 2.50
The above table shows that, according to the honey, before application in experimental group all 100%
state were in raw healing category. And after
of LSCS wound healing before and after application of administration
of honey, 7.50% were in medium healing condition and The research became authorized through the ethical
92.50% in the good healing category. committee after offering proposal with information
collection device. Where it turned into promised that
In control group LSCS wound healing on day
there may be no pain and risk to the individual. The time
1without administration of honey all 100% in raw duration of the participation can be 15 mins.The data
healing category and on 6th day 97.50% in medium might be saved confidential. The participation may be
healing condition and2.50% in raw healing category. volundary.Participant have been allowing from take a
look at after giving consent. Permission from authority
Conclusion had been taken before final examine.

The study was conducted to evaluate the

effectiveness of topical application of honey on LSCS REFRENCES
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and statistically findings shows that it is significant healing wounds.
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DOI Number: 10.5958/0976-5506.2019.01839.4

A Study to Assess the Level of Burden and Coping Strategies

among Caregivers of Patient with Affective Disorders at
Selected Hospitals of Sangli, Miraj, Kupwad Corporation Area

Ramesh Giramalla Honamore1, Narayan K Ghorpade2

1
M.Sc. Nursing, 2Assistant Professor, Bharati Vidyapeeth (Deemed to be University), College of Nursing,
Sangli

ABSTRACT
Introduction: Interactions with caregivers of patients with severe mental illness like schizophrenia and
bipolar affective disorder have revealed negative feelings about the disability status of their relative and
burden related to caring for their relative with mental illness. Many caregivers have expressed that the
patient‘s disability status affects the family pattern, roles of family members, prosperity of the family and
relationship among the family members. Patient outcome and compliance with treatment are also dependent
on optimal care giving and addressing family‘s needs. Unfortunately these needs are not routinely
considered, addressed or met. Addressing the burden perceived by caregiver and improving their coping
can assist with good clinical care of patients with severe mental illness and hence these study to assess the
burden perceived by caregiver and their coping6.
Objectives: 1. To assess the levels of Burden among care givers of patients with affective disorders.
2.To
assess the coping strategies among the caregivers of patients with affective disorders.
Materials and Method: The researcher used quantitative research approach to assess burden and coping
strategies. The research design was descriptive research design. The tool reliability coefficient ‘r’ of the
scale was 0.7, hence it was found reliable. Total 120 samples were selected by non Probability convenient
sampling technique. Total two scale namely Zarit burden interview and Rating scale for assessing coping
strategies to collect data. The conceptual framework adopted is Sr.Calista Roy’s adaptation model(1984)
the main concept of this conceptual framework is human being, stimuli, adaptation models and nursing.
Results and Conclusion: In this study found the level burden among the care givers of affective disorders
patients have experienced 60(50%)were had moderate to severe level of burden,29(24.17%) were had
severe burden, 13(10.83) were had no or little burden and 18(15%) were had mild to moderate burden and
levels of coping strategies among care givers, 19(15.83%) were had moderately adequate coping strategies,
93(77.50%) were had adequate coping strategies and 08(6.67%) were had inadequate coping strategies.
Keywords: Care giver, Burden, Coping
strategies
Introduction used nosologically as ‘bipolar’ mood disorder, has been
studied within the Indian perspective. The mood
In 1896, Kraeplin according ‘manic-depressive
disorders are commonly known as affective disorders.
psychoses’ as a circumscribed illness entity. Ever since,
Broadly speaking, the emotions can be described as
frenzied depressive mental disease, or the present
two main types Affect which is a short-lived emotional
term
response to an idea or an event, and Mood, which is a
sustained and pervasive emotional response which colors
Corresponding Author: the whole psychic life1.Caregivers of patients of
Mr. Narayan K Ghorpade, schizophrenic disorder and bipolar major affective
Assistant Professor, disorder (BAD) expertise appreciable burden whereas
BharatiVidyapeeth (Deemed to be University), caring their patients. They develop totally different cope
College of Nursing, Sangli methods to cope with this burden. Care giving is a
Email: [email protected] chronic stressor and different
229 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 229

coping methods are used to handle such a situation. The Materials and Method
present study attempts to assess coping in caregivers of
Chronic Schizophrenia and Bipolar Affective Disorder The researcher used quantitative research approach
and make a comparison between them. The study also to assess burden and coping strategies. The research
tries to assess the relationship between the burdens design was descriptive research design. The tool
experienced by the caregivers of both these groups of reliability coefficient ‘r’ of the scale was 0.7, hence it
patients with the coping strategies adopted by them. It was found reliable. Total 120 samples were selected
was a hospital based cross sectional and comparative by non Probability convenient sampling technique.
study, conducted in the Department of Psychiatry, Assam Total two scale used namely Zarit burden interview and
Medical College and Hospital with a sample size of 30 Rating scale for assessing coping strategies to collect
primary caregivers of equal number of patients of data. The conceptual framework adopted is Sr.Calista
Roy’s adaptation model(1984) the main concept of
Chronic Schizophrenia and 30 Primary caregivers of
this conceptual framework is human being, stimuli,
equal number of Bipolar Affective Disorder patients.
adaptation models and nursing.
Appropriate statistical tests were used for analysis of
obtained data setting significance threshold at p coping Assumption 1: The caregivers of affective disorders
(90%) followed by external attribution and magical patients may experience some level of burden 2. The
thinking. Among the caregivers of patients of BPAD caregivers of affective disorders patients may use some
the most commonly used coping strategies included help coping strategies.
seeking (93.33%) followed by religious coping strategies
and external attribution2.

Results

Section I: Deals with analysis of data related to assessment of the level of burden among care givers in
terms of
frequency, percentage.

Table 1: Classification of respondents based on levels of burden among care givers of affective disorders
N = 120
Sr. No. Level of Burden Score Frequency Percentage %
1. No or little burden 0-20 13 10.83%
2. Mild to moderate burden 21-40 18 15%
3. Moderate to severe burden 41-60 60 50%
4. Severe Burden 61-88 29 24.17%

The above table describes the levels of burden among care givers of affective disorders, 60(50%) were had
moderate to severe burden, 29(24.17%) were had severe burden, 13(10.83%) were had no or little burden
and
18(15%) were had mild to moderate burden.

Section II: Deals with analysis of data related to assessment thecoping strategies among care givers of
affective
disorders patients in terms of frequency and percentage.

Table 2: Classification of respondents based on coping strategies among care givers of affective disorders
N = 120
Sr. No. Strategies Score Frequency Percentage %
1. Inadequate coping strategies 01-24 08 6.67%
2. Moderately adequate coping strategies 25-50 19 15.83%
3. Adequate coping strategies 51-75 93 77.50%
230 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 230
The above table describes the coping strategies among care givers, 19(15.83%) were had moderately
adequate
coping strategies, 93(77.50%) were had adequate coping strategies and 08(6.67%) were had inadequate coping
strategies.
Discussion givers of affective disorders patients was 60(50%) were
had moderate to severe levels of burden, 29(24.17%)
The study was descriptive in nature and the
were had severe burden, 13(10.83%) were had no or little
population taken for the study was of a low
burden and 18(15%) were had mild to moderate burden.
socioeconomic status. An Exploratory study to assess
The mean percentage score was 54.71 with mean and
the level of burden and coping strategies among
standard deviation of 48.15 ± 2.75. The coping strategies
caregivers of patients with affective disorder at selected
among care givers of affective disorder using 19(15.83%)
hospitals of sangli miraj kupwad corporation area.The
were had moderately adequate coping
findings of the study have been discussed with
strategies,
reference to objective and assumption.
93(77.50%) were using adequate coping strategies
Discussion regarding demographic variables: and
Majority of the caregivers, 30(25%) were between 31- 08(6.67%) were using inadequate coping strategies.
35 years. The majority of care givers were 70(58.30%) Conflict of Interest: Nil
were females. With regard to religion, 80(66.7%) were
Hindus. Majority 69(57.5%) were graduates. With Sources of Funding: Self
regard to monthly income, 50(41.66%) were had Rs.
Ethical Consideration: Permission was obtained from
10000 -15000 income per month. In relation to the type
the research ethical committee of the Bharati Vidyapeeth
of family, 80(66.70%) were from joint family. With
(Deemed to be) University College of Nursing, Sangli
regard to duration of care giving, majority 40(33.33%)
and permission taken for data collection from Hospital
were giving for 1 to 3 years, In relation to the care givers
authority of sangli Miraj, Kupwad Corporation area.
relationship, 30(25%) were fathers, 30(25%) were son.
Informed consent was obtained from
Objective 1: To assesses the levels of Burden among individual(Samples) who are selected for the study.
care givers of patients with affective disorders: The Ethical clearance was done by head of committee
study reveals that the majority caregivers of affective members Dr shripriya and Dr. Nilima Bhore.
disorders patient 60(50%) were had moderate to severe
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DOI Number: 10.5958/0976-5506.2019.01569.9

Factors Affecting Awareness and Perception of Youth

Regarding the Public Health and Hygiene Related Campaigns
though Social Marketing

Roktim Sarmah1, Dheeraj Nim1

1
Associate Professor, Mittal School of Business, Lovely Professional University, Phagwara, Punjab, India

ABSTRACT
Social Marketing is a universally beneficial relationship between a corporation and a non-profit activity
intended to promote the former’s sales and the latter’s cause. It links economic or in-kind donations to
product sales or other consumer action. One of the interesting facts about Marketing which is Social
Marketing is the way it connects with corporate level of giving to consumers. Because of this, the Social
Marketing initiatives involve agreements in detail and also need to coordinate with non-profit partners
involving some important activities like establishing specific advertising offers, developing co-branded
campaigns.The aim of this study is to analyze Awareness and Perception of youth regarding the Social
Marketing campaigns. Five of the most popular and well known Social Marketing campaigns are
shortlisted for conducting the study on the basis of focus group discussions. The campaigns selected are
“Say No To Drugs”, “Wear a Helmet”, “Swatch Bharat Abhiyan”, “Tubecolosis” and “Usage of Sanitary
Pad”. Factor analysis is used to find out the most important factors affecting the Social Marketing.
Identified factors show that there is both favourable and unfavourable response when it comes to being
aware about Social Marketing.

Keywords: Social Marketing, Awareness, Perception,

Youth.

Introduction and their perception and awareness among youth.

These include the product featured in any campaigns,
It is generally acknowledged that Social Marketing
the donation promised to be given and the donation
is a specialized apparatus for expanding customer
received. Government of India and private agencies are
loyalty and building brand reputation. The normal
running various campaign related to social cause such as
change in an organization’s picture on account of CRM
“Say No To Drugs”,“Wear a Helmet”, “Swatch Bharat
crusades seems to rely upon a lot upon how customers
Abhiyan”, “Tubecolosis” and “Use of Sanitary Pads”.
see the explanations behind an organization’s
association in Social Marketing projects and the measure
of assistance given to the reason through an Literature Review
organization’s inclusion . Consumers with a high level
1
A cross-sectional survey was applied, with
of disbelief will be less likely to respond positively to stratification and non-probability, implying both
various CRM campaigns as compared to consumers with computers as well as paper and pen method to conduct
a low level of distrust. the survey. Findings showed that the target audience was
“Social Marketing is the process of formulating and well exposed to the anti-smoking advertisements and
implementing Marketing activities that are characterized not only this but they said that it helps them in the long
by an offer from the firm to contribute a specific amount run in lessening smoking by inculcating more initiatives
to a designated cause when customers engage in revenue among youth to quit smoking2. Ajike et al. (2016)3
providing exchanges that satisfy organisational and found that there was a significant relationship between
individual objectives”1. green Marketing and consumer buying behavior of fast
moving consumer goods in Lagos State.. The study
Social Marketing campaigns are formed from thus recommended that for green products, emphasis
various campaigns regarding the social advertisement
234 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 234

should be placed on pricing strategy in a synergistic campaign affected smokeless tobacco users as
manner. Debbie. H (2016)4 concluded that, within the follows:
Social Marketing study arena, product involvement 63% of smokeless-only users and 72% of dual users
and donation recipient specificity have received limited (i.e., those who consumed both smoking and smokeless
attention. The previous donation expression format and forms) recalled the campaign advertisement, primarily
donation scale findings have been vague and indicative through television delivery. The vast majority (over
that their effect often occurs in collaboration with other 70%) of those aware of the campaign said that it made
elements. Findings from study5 showed that Digital India them stop and think and was relevant to their lives
campaign has a visible awareness among youth mainly and provided new information. Campaign awareness
because of their television broadcasting, followed by was associated with better knowledge, more negative
Swatch Bharat Abhiyan while the least popular came attitudes towards smokeless tobacco and greater
out to be Tubecolosis campaign. Singh & Rai (2016)6 cessation-oriented intentions and behaviors among
found that students were being aware of the Marketing smokeless tobacco users.
which were telecasted frequently. Also the respondents
said that the campaigns in which contribution through Research Methodology
purchase is not required are better Social Marketing
strategies. Bina (2015)7 said that research should be Sampling Procedure and Participants: The sample of
done in the field of various elements of Social this study involves the students studying in a large
Marketing strategies. He concluded that Social Private Indian University (Lovely Professional
Marketing has good influence on consumer buying University, Punjab). Random sampling technique was
behavior. Choudhary & Ghai (2014)8 found out that used for data collection from the respondents. Youth in
Social Marketing, if done rightly, works as a great the age group of 16-35 were taken as target audience in
differentiator in FMCG as there are so many similar order to study their awareness and perception of
offerings in the market. A well rated regarding the Social Marketing campaigns. Among the
& effectively communicated cause Marketing campaign vast population of youth a sample size of 600 was taken
creates a positive impact on buying behavior of the for the study. The participation of the respondents was
young consumers in favor of the brand. Shah (2013) 9 entirely voluntary.
pointed out that people tend to attract to those
Instrumentation & Measurement: Objectives of the
companies which dwell with cause- related
research were achieved using a structured questionnaire.
Marketing. He gave the example that customers will be
The questionnaire was divided into two sections. First
interested towards those companies which do charity
part of the questionnaire comprises of questions about
or do research for the societal cause. Mir & Thokar
the demographic and psychographic characteristics
(2013)10 concluded that consumer purchase intentions
of the respondents related to participant’s gender, age,
are influenced by the charity with Social Marketing
nationality, education. Second part of the questionnaire
campaigns. Correlation and regression analysis was used
was designed to measure the awareness towards
to test the key hypothesis derived from literature of
different social causes by asking respondents to rank
positioning, brand awareness and charity in connection
these social causes in order of their preference in a
with the relationship between CRM and purchase similar way as used by Maheshwari & Suresh (2013)14.
intentions. Cheron (2012)11 found a high brand-cause Open ended questions were also asked in this section to
Marketing efficiency. Japanese female plaintiffs were know about the reason for the recall of these campaigns
showing more positive attitudes as parallel to men, individually. The secondary data was also collected from
endorsing results in previous research lessons conducted various sources like published articles, research papers,
in the West. Previous participation in philanthropic business magazines, journals, periodicals and internet
activities was also found to increase positive attitudes etc.
especially when it comes to brand- cause fit and
duration were high. Hunjra et al. (2011)12 concluded Selecting Social Marketing Campaigns: In the first
that the Social Marketing campaigns have positive phase of the research a focus group discussion was
influence on the sale activities of companies. This conducted and data was collected from 37 respondents
linkage is also intermediated by product loyalty and aged between 16 to 35 years having awareness about
buyer purchase intention that ultimately have optimistic Social Marketing campaigns being aired by government
effect on auctions. Murukutla (2011)13 showcased (NGO) agencies, both state and central and private
that
235 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 235
companies. The main purpose of this focus group
was
to generate a pool of cause related causes that could be were surveyed the majority of the respondents were
used for further use. male accounting for 54.3% compared to the females
which are 44.7%. Further the age group which showed
Before running the whole data analysis sample
major interest in filling the questionnaire was
size conducting a pilot study is important15. The same
between
has been done. Say No To Drugs”,“Wear a Helmet”,
21-25 followed by the age group (16-20), (26-30), (31-
“Swatch Bharat Abhiyan”, “Tubecolosis” and “Use of
35) respectively. The age group (21-25) accounted 69.4
Sanitary Pads”.
% of the total 600 respondents.

Results and Discussion Factors Affecting Youths Awareness Related to

Social
Reliability Statistics Marketing Campaigns

Table 1: Reliability Statistics Kaiser-Meyer-Olkin

Table 2: KMO Measure of
and Bartlett’s Test 0.877
Sampling Adequacy
Cronbach’s Alpha Based on Standardized ItemsChi-Square 2679.177
Approx.
Cronbach’s Bartlett’s Test of N of
Alpha Df Items 253
Sphericity
Sig. 0.000
0.648 0.784 13
From KMO and Bartlett’s Table, it can be
The data has a Cronbach’s alpha of 0.648. This
observed that the KMO registered a 0.877 sampling
shows that our data is reliable enough to proceed with
adequacy. This value strongly suggests that the use of
factor analysis.
factor analysis is appropriate. KMO and Bartlett’s Test
Awareness about Social Marketing Campaigns: of Sphericity both indicate that the set of variables are at
According to the study, out of 600 respondents least adequately related for factor analysis.
which

Table 3: Total Variance Explained

Initial Eigen values Extraction Sums of Squared Loadings
Component
Total % of Variance Cumulative % Total % of Variance Cumulative %
1 5.194 22.582 22.582 5.194 22.582 22.582
2 1.576 6.854 29.436 1.576 6.854 29.436
3 1.283 5.577 35.014 1.283 5.577 35.014
4 1.201 5.221 40.235 1.201 5.221 40.235
5 1.108 4.818 45.053 1.108 4.818 45.053
6 1.035 4.501 49.554 1.035 4.501 49.554
7 .993 4.317 53.871
8 .952 4.141 58.011
9 .917 3.987 61.998
10 .882 3.836 65.834
11 .876 3.809 69.642
12 .782 3.402 73.045
13 .713 3.099 76.144
14 .708 3.079 79.222
15 .681 2.959 82.181
16 .649 2.823 85.005
17 .618 2.687 87.692
18 .562 2.443 90.135
Conted…
19 .530 2.306 92.442
20 .490 2.132 94.574
21 .442 1.923 96.497
22 .421 1.832 98.329
23 .384 1.671 100.000

Based on the component matrix the 6 factors and the variables comprised under each factor are stated
below:

Table 4: Factor Table

Factors
Factors Variables
Loading
Favorable response of youth These campaigns makes me more aware and learned about
0.695
awareness towards Cause- related Social Marketing
Marketing Social Marketing provides vast knowledge to me 0.609
The ongoing Social Marketingcampaigns are really popular
0.591
Favorable perception of youth among youths
towards Social Marketing I believe the ongoing campaigns are benefitting the youths of
0.668
the country
Unfavorable awareness and perception The Concept of Social Marketing sounds irrelevant to me 0.521
towards Cause-related Marketing I connect mostly through internet and social media 0.625
There must be synchronization between product and campaign 0.709
Product & Price affects perception
towards Social Marketing Products involved in Social Marketing plays a major role in
0.751
affecting the perception towards campaigns
Free of cost campaigns related to societal causes affects me
0.505
Nature of campaigns a sensitive emotionally
decisive factor Irrespective of the price, product itself and the nature of the
0.581
campaigns are the decisive factors for me
Utilization of money at the right place with authenticity of the
0.594
Cost of campaigns a decisive factor same is important to me
Luxury goods are the most irrelevant inclusion in Social Marketing 0.593
Findings unlike Swachh Bharat Abhiyan which has covered
1. Looking into the awareness of the respective 87.2% of the respondents.
campaigns Say No To Drugs with 87.7% and 3. Some identified factors show that there is both
Swachh Bharat Abhiyan with 87.2% lies in the favorable and unfavorable response when it
most popular campaigns followed by Tubecolosis comes to being aware about Social Marketing or
with 81.7% of the respondents being aware about about the perception of the same. Favorable
the same responses
are related to getting vast knowledge through said
2. Research also reveal that respondents are aware
campaigns and unfavorable responses are like
about the government run campaigns more rather
Social Marketing is irrelevant to them.
than the private run campaigns, as we can see
the private campaigns like use of Sanitary Pads
Recommendations
has only 22.6% of the awareness while when
compared to the govt. run campaign of Swachh 1. Study showed that most of the youths are being
Bharat Abhiyan.It is hugely lacking behind as aware by watching commercials on T.V and
it’s not even has covered half of the are aware about Social Marketing campaigns.
respondents
However campaigns being run by Private brands Ethical Clearance: NA
are less popular and respondents were not
much aware about it, so in order to increase the Source of Funding: Self
awareness of these campaigns the private brands
Conflict of Interest: The authors have no affiliations
should focus more on youth’s centricity
with or connection in any organization or entity with any
awareness strategies by incorporating those
financial interest or non-financial interest in the subject
factors which grabs youth’s attention and urges
matter or materials discussed in this manuscript.
them to know about the cause as well as the
campaigns.
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DOI Number: 10.5958/0976-5506.2019.01570.5

Three Stepped Approach to Screening of Cervical and Breast

Cancer among Rural Women

Asha K. Pratinidhi1, Radhika Joshi2, Vaishali Vhawal2, Pandurang Chougule3, Sunita Tata4, Satish Kakade1
Department of Community Medicine, 2Department of Obstetrics and Gynecology, 3Department of
1

Surgery, Krishna Institute of Medical Sciences, Karad (Maharashtra) India, 4Director of Nursing Services,
Krishna Hospital and Medical Research Centre, Karad (Maharashtra) India

ABSTRACT
Introduction: Screening of cervix and breast cancer is not considered a routine activity at PHCs.
Aim and Objectives: To study a three-stepped approach of creating awareness, train ANMs while screening
and possibly continue educational and screening activity after withdrawing the mobile team.
Material and Method: A mobile team at KIMS deemed to be University, Karad, Maharashtra was formed
of specialists from concerned faculties. Four PHCs were randomly selected from the Satara district. Three
selected ASHA workers motivated fifty women >30 years to attend camp at PHC on a prefixed date. Pre-
training and post-training assessments of knowledge among women and health care workers, training of
two ANMs and Medical Officer per PHC in cervical and breast cancer screenings by VIA, VILI, and CBE
respectively while screening was done by the mobile team during intensive weekly activity of three months
at each PHC. After withdrawal of the team, PHCs were visited to see continuity of educational and screening
activities.
Results: Of 1440 women motivated by 12 ASHA workers from 4 PHCs, 1037 attended awareness
programme and 430 got screened. Of the 37 VIA positive and 17 lump in breast cases identified, one
cervical and two breast cancers confirmed cases were managed. Nonsurgical treatment was given there.
Out of four PHCs, the activity of education and screening was continued satisfactorily at two,
sporadically at one and absent at one PHC.
Conclusion: There was significant improvement in knowledge scores of community and health-care
workers after the awareness programme. The ANMs could be trained in screening cervical and breast
cancer. Education and screening activities continued after one year of withdrawal of the mobile team in
50% of PHCs. An entire district should be studied to find possible solutions of screening cervical and
breast cancer as routine activities at PHCs after this pilot project.

Keywords: Cervical Cancer, Breast Cancer,

Colposcopy
Introduction tests are available for early diagnosis of both sights of
cancers and are routinely used in the developed world
Mortality due to cancer is very high in India due to
and in urban hospital settings in India. In spite of equally
late detection of cancers. Incidence and mortality due to
high prevalence of cancer in urban and rural areas, no
cervical and breast cancer are very high and rank first
routine screening is undertaken for rural women in Rural
two sights of cancers among women [1, 2]. The screening
Hospitals (RH) or at Primary Health Centers (PHCs).
About 70% population of India resides in rural areas
Corresponding Author: where the opportunity to screen the women for cervical
Dr. Asha K. Pratinidhi and breast cancer is lost only because the health care
Emeritus Professor, workers at PHCs do not have the skill for screening and
Department of Community Medicine, the rural women are ignorant about the possibility of
Krishna Institute of Medical Sciences, screening and adverse outcome related to late diagnosis
Karad-415110 (Maharashtra) India of cancer. The rural women rarely come forward on
240 Indian Journal of Public Health Research
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& Development, July 2019, Vol.10, No. 7 240

their own for screening of breast or cervical cancer of awareness programme for HCWs as well as
and diagnosis of cancer in rural women is often very women
late and the cancer is too advanced for the life saving beneficiaries of the camp.
interventions.
During first visit to the PHC, the standard procedure
A strategy of three stepped approach i.e. step I of VIA and VILI was explained [3] and demonstrated on
health education of rural women, step II training of subjects after seeking their informed consent and giving
health care workers by a mobile team of experts to attention to privacy and confidentiality. Instructions
impart skill of screening of cervical and breast cancer about keeping the place of examination ready, making
while screening the women above the age of 30 years the instruments including Cusco’s speculum sterile and
and step III referral of suspected cases for appropriate available, preparing 5 % acetic acid from the glacial
management were therefore planned and tried. acetic acid were given and availability of Lugol’s Iodine
was ensured. Similarly the standard procedure of CBE
Material and Method namely inspection in three positions and palpation of
breast and lymph nodes was explained and demonstrated
Four PHCs namely Kale, Masur, Kole and Umbraj taking care of privacy and confidentiality after informed
were randomly selected from 11 PHCs of Karad consent of the women.
Taluka. Permission from Directorate of Health Services
was obtained and the visit schedule of twelve serial From second visit onwards hands on training was
weekly visits to each PHC was planned. A mobile undertaken while screening of beneficiaries was done by
team was formed of the specialists from Obstetrics and the specialists. During every visit to the PHCs awareness
Gynecology, Community Medicine, resident surgeon of women folk followed by screening and hands on
and nursing superintendant. training was undertaken. The MO was suggested to
keep designated day of the week as “Cancer Detection
From all available screening tests, tests to be used in Clinic Day” and to continue activity of screening after
the project were identified taking into consideration the the withdrawal of mobile team.
efficacy, availability, feasibility, affordability and ease of
carrying them out at PHC level. Visual Inspection after The project was financially supported from
application of 5% acetic acid (VIA), Visual Inspection the KIMSDU. Clearance from Institutional Ethics
after application of Lugol’s Iodine (VILI) and taking of Committee was obtained before commencement of the
PAP smear were identified as screening tests for cervical project. After completion of all twelve visits to each
cancer screening. For cancer breast, thorough Clinical of four selected PHCs, a follow up round of visits was
Breast Examination (CBE) was decided as a screening test. done to know the status of continued cancer detection
activities and to give boost to the screening activity by
Three ASHA workers were randomly identified the ANMs under the guidance of MOs.
as field level workers; two ANMs were appointed
under the project for coordination of the activities and
Results
data collection of the project in addition to two ANMs
working at each of four PHCs. ASHAs would pay home About 1000 population was covered by each ASHA
visits in their respective areas, identify the women worker; and there were about 180 women more
above 30 years of age and motivate them to attend the than
awareness and screening camps organized on specific 30 years of age. About 50 women were called for the
day of the week at the PHC where they were working. awareness programme at the time of PHC visit by the
mobile team from KIMS. The expected attendance of
During every visit to the PHC by the mobile team,
women ≥ 30 years at the PHCs was 1440. The
pre training questionnaire was filled for HCW and
women gathered for the camp. Awareness of women attendance for awareness programme was between 20 to
folk was undertaken followed by screening and hands on 30 women (40 to 60%). Out of them 10 to 12 (20 to
training of the Medical Officer (MO) and two ANMs 25%) women were ready to get examined themselves
designated by the MO of the PHC. Using same immediately after the awareness programme. A total of
questionnaire post tests knowledge scores were 430 (41.5%) women above the age of 30 years were
determined after 15 days examined out of
1037 women attending the awareness programme. There
241 Indian Journal of Public Health Research
Indian & Development,
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 241
was a significant improvement of knowledge score
in
both HCW and women attending the camp. The mean age Table 4: Signs and symptoms present among 430
of 430 women screened was 38.4 ± 8.0 years and women screened
average number of children born to them were 2.4
and Associated findings Frequency %
14 (3.3%) were nulliporous. The profile of the Backache 199 46.3
women Leucorrhoea 85 19.8
who could be screened was as follows. Abdominal pain 75 17.4
Irregular Menstruation 63 14.7
Table 1: Martial status of 430 women screened DUB 28 6.5
Uterine prolapsed 17 4.0
Frequency %
Infertility 14 3.3
Married and staying with their
Uterine Cervical Polyp 393 4 91.4 0.9
husbands
Widows Uterine fibroid 34 3 7.9 0.7
Separated/Divorcee Total 03 488 0.7 100
There were 39(9.1%) women VIA/VILI positive
and 17(4%) women were detected as having lump in the DUB: Dysfunctional Uterine Bleeding
breast. Pap smear was taken for 210 (48.8%) women.
There were 52 (12.1 %) women who did not
have any symptom and on vaginal examination were
Table 2: The Pap smear cytology results (TBS clinically normal. Number of signs and symptoms
2001)
were more than one in 60% women. Out of 85 patients
Histopathological findings Frequency % in need of management, 12 were suspected cases of
NILM 202 12.4 cancer cervix and 17 suspected cases of cancer
breast,
ASCUS 04 01.9
49(57%) were treated for infection, and 10 had surgery
LSIL 04 01.9
for associated findings not related to cancer cervix like
Total 210 100 fibriod, polyp, prolapse. Four underwent Loop Electrical
NILM: Negative for Intraepithelial Lesion or Excision Procedure (LEEP), four were treated with cryo
Malignancy ASCUS: Atypical Squamous Cells of cauterization for precancerous lesions and one received
Undetermined Significance, LSIL: Low Grade chemotherapy. Thus, out of 12 suspected cases of cancer
Squamous Intraepithelial Lesion cervix, 8 were precancerous lesions and were treated
with excision or ablation and one was treated with
Calposcopy was done on 99 women at primary chemotherapy for cervical cancer. Three cases were lost
centre by the mobile team. Their colposcopic findings for follow up. Out of 17 suspected cases of breast cancer
were as follows 2(11.2%) were identified as breast cancer and underwent
appropriate management and remaining were benign
Table 3: Colposcopic findings of suspected cases at lesions. Two were operated for breast cancer. Out of
PHCs four PHCs in two centres, the activity of screening was
continued satisfactorily, at one centre the activity was
Colposcopic findings Frequency % not up to the mark and at one centre it was totally absent
Normal 63 63.6 where the MO was on the long leave.
Ectopy 09 09.1
CIN 12 12.1 Discussion
Unsatisfactory 10 10.1
Atrophy 05 05.1 Cancer of cervix and the cancer of breast are best
suited for early detection as both sites are accessible;
Total 99 100
cancer begins as localized lesion after a long period
CIN: Cervical Intraepithelial Neoplasia of existence of pre malignant lesions which can be
identified by the screening tests.
All 99 cases undergoing calposcopy were VIA
positives. Twelve of them were positive for Screening for cervical cancer by PAP smear is
precancerous lesions by calposcopy. an
accepted clinical practice, which requires laboratory
equipments and trained personnel. VIA and VILI are 30 women at a time with audiovisual aids resulted in a
alternative screening tests which are equally effective significant improvement in knowledge scores in both.
and sensitive which are less expensive, easy to carry The women could understand the role of known risk
out and the skill can be easily transferred to healthcare factors like age of women at marriage, early marriage,
workers [4]. and possibility of infection with HPV due to multiple
SBE, CBE, Mammography, Ultrasonography and sex partners, early menarche, multiparity and lack of
thermography are tried for screening of breast cancer. cleanliness during menstruation and delivery for cervical
Mammography is the most sensitive and specific method cancer as well as family history, age, nulliparity, early
but there is risk of exposure to radiation which is menarche and late menopause, high fat diet and obesity,
manifold more than the dose received by chest X-ray exposure to radiation for breast cancer as risk factors.
and increases the risk of development of breast cancer The motivation to get themselves screened due to
itself [5]. Secondly it requires an equipment of high awareness generation was evident by acceptance of
standard and an experienced radiologist for its screening by 430 (41.50%) women out of 1037 women
interpretation which increases the cost of screening. attending the camp.
It may lead to the increased number of biopsies of
suspicious lesions with a high possibility of false Step II was skill transfer. Four MO and 8 ANMs
positive results. Thermography is not associated with could be trained by mobile team with twelve weekly
radiation exposure but the sensitivity is low [6]. visits. Out of four PHCs, two PHC continued awareness
activity, screening and referral proactively, one PHC
American College of Obstetricians recommended was carrying out the activities but did it passively, i.e.;
both SBE and CBE. Cochrane review on self breast only those women > 30 years who attended the PHC for
examination has revealed that SBE has no impact on any reason were screened and referred and at one PHC,
cancer mortality. There can be poor compliance with no activity related cancer detection was going on
follow up and increased number of biopsies performed where MO was on long leave after end of year of the
on benign lesions [7]. project. There is a scope for improvement. Now all MOs
In rural India, the women are illiterate and may not and ANMs are trained under the cancer component of
be able to learn correct technique of self breast non- communicable disease control programme. If the
examination. CBE if carried out carefully giving MO as a team leader is motivated and ensures the
attention to technique and thoroughness may be an availability of acetic acid and Lugol’s iodine, charts
effective screening tool. Although no trials are available are prepared and displayed at the PHCs, field level staff
for comparing CBE alone to no screening but Canadian during their routine home visits or for any other health
National Breast Screening Study-2 (CNBSS-2) [8] related activity motivates the women above 30 years to
included randomized screening of 39405 women aged come to PHC on a fixed day of week for awareness and
50-59 years in two groups. Group one was CBE alone screening activity at least 30-40% of the women will
and the second group was CBE with mammography. No get benefit of early diagnosis of cancer cervix and
mortality advantages was seen when mammography was cancer breast.
added to annual standardized 10-15 minute breast At present screening for cervical cancer at PHCs is
examination implying that careful CBE may be undertaken sporadically as a special health camp in
effective as mammography. Thus for screening of some places near about specialized centres or cancer
women from rural areas for cancer breast and cancer hospitals but not routinely done as an ongoing activity
cervix in developing countries like India at PHCs on a fixed day as cancer detection clinic. There is a
constrains are with limited resources and skilled possibility of implementing this, three stepped approach
manpower. This project can be considered as a pilot in all PHCs for primary and secondary prevention of
project. CBE, VIA and VILI could be considered as breast cancer and cervical cancer at PHCs for the rural
appropriate screening tests. population by making it as a routine activity of the PHC
Step I of the strategy was imparting knowledge about may be once in a week, once in a fortnight or once in a
cancer of breast and cervix to HCW and women month.
attending the camps. Awareness programme conducted There are medical colleges public or private in
for about almost all districts of Maharashtra. If advantage is taken
of the expertise of these medical colleges under NCD Cytology and Gynaecological Pathology, Post
programme, it will go a long way in preventing and down Graduate Institute of Medical Education and
staging the two most common sites of cancers in females. Research, Chandigarh, India, 2006.

Source of Funding: Intramural funds of Krishna 5. Tabár L, Fagerberg CJ, Gad A, Baldetorp L,
Institute Holmberg LH, Gröntoft O, et al. Reduction in
of Medical Sciences “Deemed to be University”, Karad mortality from breast cancer after mass screening
with mammography. Randomised trial from the
Conflict of Interest: Nil Breast Cancer Screening Working Group of the
Swedish National Board of Health and Welfare.
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Jacques Ferlay, Elizabeth Ward, David Forman. Gynacologists Breast Cancer Screening ACOG
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3. Padubidri VG, Daftary SN. Howkins and Bourne 8. Miller AB, To T, Baines CJ, Wall C. Canadian
Shaw’s Textbook of Gynaecology. 6th Edition. National Breast Screening Study-2: 13-year
Reed Elsevier. 2002: 488-9. results of a randomized trial in women aged 50-59
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cancer screening programme, Department of
DOI Number: 10.5958/0976-5506.2019.01571.7

Single-Visit versus Dual-Visit Endodontics—

A Comparative Study

Sanjay M Londhe SM1, Sonali Sharma2, Sheetal Lal3

1
Director General Dental Services, PHDS and Col Comdt AD Corp. Room No 11, L Block, Adjutant
General’s Branch, IHQ of MOD (Army) New Delhi, 2Professor and Classified Specialist
Conservative Dentistry and Endodontics, Army Dental Centre R and R, Delhi, 3Dental Officer Ex AD
Corps

ABSTRACT
Traditionally root canal treatment was completed in multiple visits so as to eradicate microorganisms and
maintain sterility of prepared canals. Currently evidence based studies have shown that there no difference
in healing potentiality of single visit as opposed to dual or multiple visits. Modern concepts and protocols
in diagnosis, instrumentation, disinfection and obturation systems have made single visit endodontics
(SVE) a faster regimen with a predictive outcome. Clinical study aimed to investigate the effectiveness of
single visit as compared with dual visit endodontics was conducted. 399 adult patients with pulpal and
periapical diseases of endodontic origin who were selected for endodontic therapy in various dental centres
in Delhi were included in the study. 201 cases underwent single sitting (Group A) and 198 were treated in
two visits (Group B). Endodontic failure rate of 3.68 % was observed in single visit group as opposed to
4.78 % in dual visit. Though statistically there was no significant difference in outcome of both protocols,
the advantages of SVE outweigh those of dual visit. Thus single visit endodontics can serve as an
acceptable, alternative treatment modality as compared to dual or multiple visit endodontics.

Keywords: Single visit endodontics, root canal

treatment
Introduction have refined the end point of endodontic success.
This
Single visit endodontics (SVE) is defined as “the has given the much-needed impetus to SVE [2- 3].
conservative nonsurgical treatment of an endodontically
involved tooth consisting of complete biomechanical The main indications for single visit endodontics
cleaning, shaping and obturation of the root canal are in vital teeth which are exposed due to trauma or
system during one visit” [1]. Concept of SVE has been any other mechanical cause. It is also advocated, when
mired in controversy for over a couple of centuries. It intentional endodontics is an inescapable necessity for
was first documented by Dodge in 1887.The primary prosthetic rehabilitation to correct axial inclination of
reason it was not embraced universally was due to the abutment. It is contraindicated for patients suffering
unresolved issues like differences in clinical outcomes, from muscular dystrophy or any psychiatric condition
microbiological concerns as determined by culture which may prevent them from cooperating for the
testing and post obturation pain. Endodontic success or long duration of the single visit protocol. In cases of
end point was till recently solely determined by culture anatomical variations or procedural errors it may be
testing which was neither a specific or sensitive tool. difficult to perform endodontics in single visit [3-4].
Today newer materials, techniques and scientifically
proven concepts Material and Method
A study aimed to investigate effectiveness of single
Corresponding Author: visit as compared with dual visit endodontics was
Lt Col Sonali Sharma conducted. Adult patients with pulpal and periapical
A 201 Winter Hills Dwarka Morh, Delhi-110059 diseases of endodontic origin who were selected for
Phone: +9197178885133 endodontic therapy were included in the study. Cases of
Email: [email protected] acute apical periodontitis were not included in the study.
245 Indian Journal of Public Health Research
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 245

Procedure and analysis. The unit of analysis was the tooth and teeth
were referred to as cases. Median survival time was
Patients fulfilling the inclusion criteria were enrolled
compared using Wilcoxon test. At the bivariate levels,
in the study and preoperative radiographs were taken
the following independent variables were assessed:
by digital radiographic machine. The size of periapical
patient’s gender, age and treatment modality. The
lesion was noted, both in horizontal and verical axis and
student’s ‘T’ test was used to determine whether there
it served as a baseline record. The anterior and posterior
was a statistical difference between expired and survived
teeth were randomly divided into two groups, Single
in the parameters measured. Chi-square was used to
sitting i.e (GROUP A) and Dual sitting i.e (GROUP B).
ascertain the association (or independence) between
Some patients had multiple teeth which were indicated
category variables assessed.
for nonvital endodontics, in such a situation each
Clinical Case—Single Visit
selected tooth of the patient was taken as an unit and
referred to as a case. A total of 399 cases were included
with 201 cases in Group A and 198 in Group B. In both
the groups there were 98 posterior teeth and remaining
anteriors. Standardardized endodontic protocol was
followed in both groups by three operators. The selected
tooth was isolated with rubber dam and disinfected with
2 percent sodium hypochlorite. The access was prepared
with cavity access burs. Caries and old restoration was
removed at this stage. The patency of the canal was
achieved with a
6/8/10/15 nos K FILE of 21mm length for posterior
teeth and 25 mm length for long rooted anteriors. The
working length was radiographically determined. The
cleaning and shaping was done using NiTi Hyflex files
as per the advocated sequence by manufacturer.
Recapitulation was done sequentially. Canals were
irrigated with sodium hypochlorite and EDTA gel was
used as a chelating agent. The canals were dried with
paper points. The guttapercha point corresponding to the
last file used in apical preparation was selected and a
master cone selection radiograph was taken. The canal
were dried and coated with AH plus sealer. The master
cone was also coated with sealer and was placed in the
canal. Additional acessory cones were placed in space Figure 1
created by spreaders. The canals were obturated 1a) Preoperative radiograph. 1b) Working length
following the lateral condensation method. The access determination radiograph shows shadow of
filling was done with either glass ionomer alone or a another root, confirmed by modification of access
combination of glass ionomer and composite. High preparation & repeat working length determination.
points if any were removed ( FIG 1). For Dual Sitting, 1c) Master Cone Selection.1d) Obturation. 1e)
the same protocol was followed, except that in the first Follow Up-3 Months. 1 f) Follow Up 9 Months
sitting the canal was prepared and an intracanal
dressing of calcium hydroxide was given and a Clinical Case—Two Visit
temporary restoration placed. In the next sitting the canal
was obturated as in single sitting group ( FIG 2). The
indices used in this study were PAI [(Periapical index)
preoperatively and during follow Up] and Strindberg
criteria as an evaluation tool. Both Groups were
evaluated clinically at 7, 15, 30 days and a 9 month
follow up was done. The result were computed,
correlated and subjected to statistical analysis. The
following models of statistical analysis have been used
in this study. The Excel and SPSS 16(SPSS Inc,
Chicago) software packages were used for data
entry
Graph 2: Correlation of Postoperative Periapical
Status and Failures

Graph 3: Correlation of Preoperative lesion size,

Figure 2 Strindberg criteria and failures at 9 months
2a) Preoperative radiograph. 2b) Working length
determination radiograph. 2c) Master Cone
Selection.2d) Obturation. 2e) Follow Up-3 Months. 2
f) Follow Up 9 Months

Results
Results are summarized in the graphs (1-3). There
was equi gender distribution of cases. The mean age
group was 3rd and 4th decade, however age and gender
had no bearing on the failure rate. The endodontic
failure rate of 3.68 % was observed in single visit group
as opposed to 4.78 % in dual visit. Graph 4: Correlation of Postoperative lateral seal
and length of root filling on failure rate

Discussion

Currently with the changing concepts of the

endodontic protocol, the use of contemporary
endodontic techniques not only reduce the treatment
time but also increases the success rate, and this has led
to single visit endodontics being revisited [1-4]. However
the contemporary question “Is single visit root canal
treatment a biologically compromised treatment?” has
Graph 1: Correlation of Preoperative Periapical not been conclusively answered, although numerous
Status and Failures studies have addressed various aspects of this clinically
relevant query [1, 3]. This study was undertaken to we used calcium hydroxide in-group II cases without
compare contrast and correlate both the modalities of finding any significant difference in healing between the
treatment and to assist clinicians in making informed two groups. Studies by Sathorn,and Fava have proved
treatment protocols made on current thought-provoking that there is a similar healing pattern in periradicular
evidence based scientific data. region in both protocols [4,11]. Complete elimination of
bacteria is not strictly necessary and maximum reduction
Case selection has a definitive bearing on the
of bacteria and effective canal filling may be sufficient
outcome. Trope et al found that there was no flare –
in terms of healing. [7-9]. In the present study we used
ups in cases without preexisting symptoms [5-6]. Studies
calcium hydroxide in-group II cases without finding any
have shown that teeth with periapical radiolucency
significant difference in healing between the two groups.
exhibited less pain than nonvital teeth without
Our findings are in agreement with past studies [11-13].
periapical radiolucency [1-3]. In this study, for uniformity,
the inclusion criteria were patients of either gender Pain and swelling are the signs that the underlying
above 18 years of age exhibiting the following cause is a diseased tooth. Root canal treatment aims
conditions: irreversible pulpitis, chronic apical to result in resolution of the disease process and in
periodontitis, nonvital/necrotic teeth. Teeth with the bargain the patient is free from the associated
compromised periodontal status, acute apical sign and symptoms [14]. Lot many dentists believe that
periodontitis and acute alveolar abscess were excluded postoperative pain is sequelae of single visit endodontics
[15-17]
from the study. . The causative factors of flare-ups encompass
mechanical, chemical and or microbial injury to the pulp
Studies by Sathorn et al [4] and Spanberg et al [7] or periradicular tissues. Of these factors,
concluded that small sample size would give a skewed microorganisms are the main causative factors leading
statistical analysis. Statistical power is the likelihood to flare ups [18-20]. Eleazer and Eleazer reported fewer
that a study will detect an effect when there is an effect flare-ups for the single-visit group (3.0%) than (8.0 %)
there to be detected. If the statistical power is high, the for the multiple- visit group [21]. In the present study on
probability of making a Type II error, or concluding reviewing patients soon after the completion of the
that there is no effect when in fact there is one, goes treatment protocol and reviewing again at seven days
down. Statistical power is affected chiefly by the size and fifteen days, there was no increased incidence of
of the effect and size of the sample used to detect it. pain with single visit protocol as compared to dual visits.
Hence in the present study sample size of 201 teeth Numerous studies evaluating the postoperative pain
were included in Group A – single visit protocol after RCT have been published, with the incidence of
and postoperative pain ranging from
198 teeth in Group B - dual visit protocol. The samples 1.9%–48%, and they showed conflicting findings [20-24].
were randomly assigned to each group to remove any In the present study the incidence of postoperative pain
bias. Observer calibration was conducted by twice was not attributable to the number of visits. This was in
scoring a set of 100 case on individual radiographs. confirmation to study by Hammed et al [25].
The “true score” was by consensus of two dentists
In our study outcome of treatment was classified
involved in the study. Radiographs were independently
by using modified Strindberg criteria and Periapical
assessed by two examiners. The size of periapical
Index both preoperatively and postoperatively
radiolucency was calculated by measuring with a ruler
[Graph1
tool on radiovisiography (to the nearest millimeter) its
- 3]. Teeth with symptoms of persisting periapical
largest horizontal and vertical width. This methodology
inflammation were scored as not healed as were cases
was consistent with all radiological studies in field of
with increased size of the periapical radiolucency. Teeth
endodontics [1, 4, 8-9].
with a reduced size of the periapical rarefaction at end
One of the major causes of apical periodontitis is of 9 months follow up (sum of horizontal and vertical
attributed to microorganism inhabiting the root canals reduction 2 mm) were judged as healing. Teeth with
[10-12]
. Cleaning and shaping with meticulous irrigation complete restitution of the periodontal contours were
protocol will only reduce bacterial load by 40-60% judged as healed. Teeth with unchanged size were
[12]
. Thus, the use of an antibacterial inter-appointment registered as uncertain. In teeth with more than one root,
medicament was advocated. Hence In the present study the least favorable outcome was registered.
In a Cochrane systematic review of single versus . In the present study it was observed that whenever
25-27]

multiple visits endodontic treatment, Sathorn concluded the lateral seal as well as apical seal was violated,
that no detectable difference was found in the the incidence of failure increased.Teeth that are not
effectiveness of root canal treatment in terms of satisfactorily obturated show higher rate of failure.
radiological success [4]. In the present study it was found Unsatisfactory and incomplete obturation was minimal
that the failure rate or the rate of healing was more in this study.
consistent in teeth, which did not have a discernible
periradicular rarefaction. It was also found that
preoperative asymptomatic teeth with apical
periradicular lesion of 2-5 mm in diameter were healing
at the end of the follow up in both the groups. But the
success rate diminished with increase in size of
preoperative lesion (Graph 1, 2, 3). These finding were
constant irrespective of the number of visits. Complete
resolution of periapical lesion was not recorded; this
could be because the follow up time was limited to 9
months. One-year follow up time is the soonest possible
to determine whether or not the lesion has healed [9-
10]. But marked reduction in lesion size was noted
in
60 % of cases in single sitting group as compared
to
53.72 % in dual sitting group. Discernible healing
was
seen in 35.7 % of single visit group as compared
41.4
% in dual visit. Thus there was no statistical difference
between healing between the two groups (Graph 1-3).
The differences in size of periapical lesion between
subjects of treatment groups at entry to end of the study
might act as a significant confounder. The differences in
severity of apical periodontitis (high PAI score) might
affect healing time and/or chance of healing. Healing
was judged as a decrease in the PAI score overtime [26-27].
Decrease in PAI values at follow up has been taken as a
predictor for healing, as a complete resolution of healing
in a short follow up is not possible. A longer follow up
of
2- 3 years would be required for evaluating preoperative
lesions size of greater than 5mm.

In the present study, the endodontic failure rate

of
3.68 % observed in single visit group as opposed
to
4.78 % in dual visit, seemed to compare favorably with
published values given by Yingying Su [4-7]. Failures
are observed more in teeth in which there has been less
than acceptable limit of obturation and in which the
preoperative lesion is more than 5mm periradicular [3, 9,
Each study has its limitations and no study is
flawless [28], as is envisaged in this study. The most
reliable way to assess the clinical impact of a novel
technique is through its effect on a well-defined clinical
endpoint such as healing of a radiographic lesion.
However, this may be impractical, due to a prerequisite
of large sample size and a long duration of time
required for these clinical endpoints to be achieved.
Healing of apical periodontitis, for example, may take
many years to show clearly on radiographs [8,9,25-28]. A
surrogate endpoint is defined as a biomarker that is
intended to substitute for a clinical endpoint [29-30]. A
surrogate endpoint is expected to predict clinical benefit
based on epidemiologic, therapeutic, pathophysiologic,
or other scientific evidence. Thus, correlating our
clinical out come over a longer follow up period with a
surrogate end point would have made the present study
more stringent.

Another limitation of this study is that a patient

preference of both the protocols has not been assessed.
Various studies have concluded that patients should be
involved in treatment decision-making [4, 8-9 28-30]. The
introduction of the patient’s point of view in quality and
effectiveness studies can be considered a further step
towards a more comprehensive humanistic approach to
the patient.

Conclusion
Though statistically there was no significant
difference in outcome of both the protocols, single visit
endodontics advantages outweigh those of dual visit
protocol : number of patient appointments is reduced
leading to increased level of patient comfort, the
chances of inter-appointment microbial contamination
and associated flare-ups caused by leakage or loss of
the temporary seal are reduced, an immediate aesthetic
replacement can be given for anterior teeth, there is no
need for re familiarization with the canal anatomy at the
recall appointment. The therapy is cost-effective as there
is reduction in clinical time.

Ethical Clearance: Institutional (ADC R & R)

ethical
clearance obtained.

Source of Funding: Declaration of AFMRC Project:

This paper is based on Armed Forces Medical Research
Committee Project No 4256/2012 granted by the office
of the Directorate General Armed Forces Medical
Services and Defence Research Development
Organization, Government of India.

Conflict of Interest: Nil

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DOI Number: 10.5958/0976-5506.2019.01572.9

A Study to Evaluate the Effectiveness of Ginger Tea on

Morning Sickness among Antenatal Mothers in Selected Area
of Sangli, Miraj, Kupwad, Corporation

Seema D Shiradwade1, MS. Regina Satvekar2

1
MSc 2nd Year Nursing, 2Assistant Professor, Bharati Vidyapeeth (Deemed to be
University), College of Nursing, Sangli

ABSTRACT
Quasi experimental research study was conducted during the month of August 2018 with the aim of
establishing the effectiveness of ginger tea in reducing the morning sickness. Total of 60 antenatal mothers
were selected and grouped into 30 in each for experimental and control respectively. The subjects were
selected by using Non probability purposive sampling technique. The level of morning sickness was
evaluated by using modified Rhodes index scale among antenatal mothers. The intervention was exercised
i.e. Ginger tea 200ml once in a day for 5 days was administered to the subjects of experimental group. The
reliability of the tool was determined by using split half method. The reliability coefficient “r” was more
than 0.7, hence the tool was found to be reliable. Also, 30 eminent experts from all over India had validated
the tool for its content. Data was analyzed using descriptive ie. Frequency and percentage distribution,
inferential statistics ie. ‘t’ test, z test.
Study results showed that, the ginger tea is effective on morning sickness and statistically there is
significant difference in the experimental and control group. Hence study concludes that there is
significant effect of ginger tea on morning sickness among antenatal mothers

Keywords: Effectiveness, Ginger tea, Morning sickness, Antenatal mothers

Introduction backaches, these changes may be sudden and it occur in
some women by unknowingly.3
During pregnancy every woman have different
experience and it is wonderful response when pregnancy The woman experiences with sudden and dramatic
is confirmed and maximum woman have experience increases in estrogen and progesterone during pregnancy
normally in early pregnancy with Morning sickness intended to aid the fetal and maternal development.
that means nausea and vomiting, and slowly adjusted Nausea associated with pregnancy in first trimester
to it.1 During 9 month of pregnancy period, various because of fast increase in estrogen level.4
physiological changes are experienced by pregnant
women. Some physical changes are, growing abdomen Seventy to eighty percent of all pregnant woman are
size, increasing body weight till 9 months that is, the encountering NVP. Most of the women have NVP only
normal weight is up to 10 to 11 kg, morning sickness in 1st trimester whereas, very thin population of
and pregnant mother’s experience a long period of NVP
extended until the initiation of labour process. The
data of pregnant women affected with NVP in US and
shows that, around
Corresponding Author: 4,000,000 and 3, 50,000 women are experiencing the
MS. Regina Satvekar symptoms of NVP each year respectively.5
Assistant Professor,
Bharati Vidyapeeth (Deemed to be University) Usually nausea and vomiting begins at 6-7 weeks of
College of Nursing, Sangli gestation, and it peaks at 9-13 weeks, and decreases in
Email: [email protected] most cases by 12-14 weeks with a symptoms of nausea
252 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 252

and vomiting. Symptoms continue beyond 20 weeks in cold, headaches, painful menstrual periods, flu, like
up to 10% of pregnancies. Estimates that, 1 in 5 women symptoms ginger treatment is helpful. Even nausea and
suffer with morning sickness in 2nd trimester and few vomiting during pregnancy, ginger is more effective
for the complete duration of their pregnancy.6 A survey treatment or prevent nausea and vomiting in pregnancy
findings reveal that, woman’s having nausea and and cancer chemotherapy. And several human research
vomiting at 2nd week of gestation, 73 of 409 women studies say that ginger is most effective treatment for
(17.8%) were having nausea without vomiting and short day use of 1gm daily may decrease nausea and
from 409 (2.7%) in that 11 women’s were having vomiting in pregnant women.14
nausea with vomiting..7
It is the most common disorders during pregnancy Ginger contains phenolic are known to treat of
and relieving gastrointestinal irritation, stimulate saliva and
affecting almost 80% of pregnant women.8 bile production, and reduces gastric contractions as food
and fluid move through GI tract. Ginger provides variety
A cross sectional study among Norwegian of vitamins and minerals that are carbohydrates,
population shows that, Total of 712 women had calories, fiber, protein, sugar, sodium, iron, vitamin-C,6
nausea and vomiting during pregnancy in that 62% had vitamin-B , Magnesium, Phosphorus, Zinc, Folate,
mild, 439% had moderate, and 210 were having severe Riboflavin, and Niacin. Ginger root is true storehouse of
nausea and vomiting pregnancy.9 Eight nine percent of vitamins and minerals that are necessary during
women were nauseous in early pregnancy, in that pregnancy.15
most commonly, the NVP experienced was mild (48%)
moderate (30%) and sever 11% had experienced nausea By considering above all ginger in pregnancy, mode
vomiting during early pregnancy.10 of action of ginger on morning sickness and the
scientific evidences I feel that nothing beats morning
Nausea and vomiting is the most common medical sickness like cup of ginger tea.so rather than treating
condition in pregnancy, affecting 50-90% of women (NVP) with anti- emetics it is always better and safe to
Nausea and vomiting of pregnancy can have a profound treat by ginger tea. Hence the investigator felt to select
effect on a woman and her family’s health and quality this topic as project in order elicit the usefulness of
of life, therefore early recognition and management is ginger as home remedies and medicinal benefits while
important. 6 managing the patients with morning sickness,
As there are increased rates of nausea and vomiting specifically about the ginger tea as to how it helps in
in early pregnancy; the women and health professional’s pregnant women when they suffer from morning
needs to create and adopt the optimal guidance and sickness.
effective & safe intervention to manage the event.11
Objectives
Traditional Chinese medicine, Ayurveda, traditional
Thai medicine, Japanese Kampo medicine, and several 1. To assess the level of morning sickness
before
other traditional medicines around the world, says that
administration of ginger tea.
ginger is a basic herbal treatment, ginger can treat
numerous disease and further investigations are showing 2. To evaluate the effectiveness of ginger tea on
the clue of health related benefits.12
morning sickness after administration of ginger
tea.
Ginger has “Gingerols” and “Shogaols” and that
acts as most vigorous elements in ginger are the pungent 3. To compare the morning sickness between
principles, and related clinical studies have assessed that experimental and control group.
for nausea and vomiting during pregnancy, ginger as an
effective and safe treatment.13 Materials and Method
Ginger named, the root or the rhizome of the plant A quantitative pre-experimental one group pre-test
‘Zingiber Officinale’. Ginger is considered as herbal and post-test design was used to evaluate the
medicine and popular spice for thousands of years and effectiveness of ginger tea on morning sickness among
it has a long history of use in Asian, Indian and Arabic ANC mothers in selected area of Sangli, Miraj and
herbal traditions. Minor health problems like Kupwad corporation area. The conceptual framework
common
253 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 253
based on the general system theory, introduced by
Ludwig von Bertalanffy
(1968) with input, process, output and feedback. The Hypothesis
reliability was statistically computed by using split-half
method. The “r” value 0.86, which was more than 0.7 HO : There is no difference in the morning sickness after
hence the tool was found to be reliable. Validity was administration of ginger tea among antenatal mothers.
done from 35 experts. Total 60 sample were selected H1 : There is difference in the level of morning sickness
by non-probability convenient sampling technique was after administration of ginger tea among antenatal
used. A Modified Rodhes Index Scale was administered mothers
to collect data.

Findings

Section I: Frequency and percentage distribution of demographic variables.

Table 1: Frequency distribution of ANC mothers according to demographic variables

Sl. Experimental Group Control Group
Variable Category
No. Frequency % Frequency %
15-25 18 60 24 80
1 Age in year
26-35 12 40 6 20
No Formal Education Nil Nil Nil Nil
Undergraduate 22 73.33 19 63.33
2 Education
Graduate 07 23.33 09 30
Post graduate 01 3.33 02 6.67
Housewife 29 96.67 28 93.33
3 Occupation Staff Nurse Nil Nil 02 6.67
Clerk 01 3.33 00 00
10-20. 17 56.67 24 80
Gestational
4 21-30 11 36.67 06 20
week
31-40 02 6.67 Nil Nil
Vegetarian 06 20 07 23.33
5 Diet pattern
Non Vegetarian 24 80 23 76.67
Primi 18 60 15 50
6 Gravida
Multi 12 40 15 50
Primi 12 40 15 50
Para P1 10 33.33 13 43.33
P2 04 13.33 01 3.33

Section II: Asses the level of morning sickness before and evaluate after the administration of ginger tea
in
experimental and control groups.

This section deals with the effectiveness of ginger tea among ANC Mothers with morning sickness
A. Level of morning sickness before the administration of ginger tea.

Table 2: Level of morning sickness before the administration of ginger tea in both group
N = 3 0 + 30
Level Experimental Group (Day-1) Control Group (Day-1)
Groups Frequency % Mean SD Frequency % Mean SD
Mild 02 6.66 6.5 2.12 03 10 7.33 1.15
Moderate 22 73.33 12.9 2.06 27 90 12.66 3.23
Sever 06 20 17.5 0.83 00 00 00 00
Total 30 100 30 100
B. To evaluate the effectiveness of ginger tea on morning sickness within experimental group:

Table 3: Effectiveness of ginger tea on morning sickness after administration of ginger tea in experimental
group
N = 30
Group Frequency Mean S.D ‘t’ value ‘P’ value
Before administration on day 1 30 12.80 3.32
11.31 0.000
After administration on day 5 30 5.70 1.82

Section III: To Compare between experimental and control group

A. Compare the morning sickness in experimental group.
Table 4: Effectiveness of morning sickness in experimental group
N = 30
Experimental Group Frequency Mean S.D. ‘t’ value ‘P’ value
Day 1 30 12.80 3.32
11.31 0.000
Day 5 30 5.70 1.82
B. Compare the morning sickness in control group.
Table 5: Compare the morning sickness in control group
N = 30
Group Frequency Mean S.D. ‘t’ value ‘P’ value
Day 1 30 12.13 3.48
5.80 0.000
Day 5 30 8.73 2.58
C. Comparison of morning sickness after the day 5 in Experimental and Control Groups

Table 6: Comparison of morning sickness after the day 5 in Experimental and Control Groups
N = 30 + 30
Day 5 Frequency Mean S.D. ‘t’ value ‘P’ value
Experimental 30 5.70 1.82
5.25 0.000
Control 30 8.73 2.59
Conclusion z Nurses can encourage the patients to adopt the
consumption of ginger tea, as it is cost effective,
Based on objective and the hypothesis, the collected safe and natural source.
data was analysed by using descriptive and inferential
statistics. And the `z test was used to find the z Community health nurses and midwives can
significance. take the lead in implementation of the ginger tea
intervention in reduction of morning sickness.
Ginger tea is effective on morning sickness and z Nurses can further brain storm about the
statistical findings showed that there is significant effectiveness of ginger tea on morning sickness at
difference in the experimental and control group. Hence large platforms such as conference, workshop, and
study concludes that there is significant effect of ginger seminar.
tea on morning sickness among antenatal mothers.
Nursing Education
Recommendations & Implications z Study highlights the knowledge related to usefulness
of ginger in management of morning sickness.
Nursing Practice: Based on the study findings,
z It is impetus to include the information related to
z Nurses can focus their independent the ginger and its uses into higher and/or institution
nursing level curriculum.
intentions towards such natural remedies,
z Nurses can have educated regarding the role of (Deemed To Be) University College of Nursing,
ginger in reducing morning sickness. Sangli, and permission taken for data collection from
z Student nurses can adopt the techniques and Sangli Miraj Kupawad Corporation Area. Informed
usefulness of ginger tea on management of morning consent was obtained from individual (samples) who
sickness. are selected for the study. Ethical clearance was done
by head of committee members Dr. Sripriya and Dr.
Nursing Administration Nilima Bhore.
z Nursing administrators, can frame the proactive
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29. Ozgoli G, Goli M, Simbar M. Effects of ginger
Galai N, Schisterman EF. Association of nausea capsules on pregnancy, nausea, and vomiting. J
and vomiting during pregnancy with pregnancy Altern Complement Med. 2009 Mar;15(3):243-6.
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clinical trial. JAMA Intern Med. 2016 Nov Rezaiie M, Farhadifar F. Comparing the effects
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DOI Number: 10.5958/0976-5506.2019.01573.0

Contraceptive Methods: Knowledge, Practice and their

Attitude among the Women of Rural Population in and around
Bangaluru City of Karnataka State, India

SenigalaKuruba Anusuya1, Sudha Patil2

1
Associate Professor, 2Professor, Department of OBG, Akash Medical College and
hospital, Bangalore, Karnataka State

ABSTRACT
The main objective of this study was to assess the knowledge attitude and practice of contraceptives in rural
women. this is across sectional study of rural women between 20-45 age groups attending the Outpatient
department of obstetrics & gynaecology at AIMS&RC situated at Devanahalli rural Bengaluru, Karnataka.
Methodology- 500rural women were interviewed by giving the questionnaire which assesses the KAP of
contraception and the various methods like barrier intrauterine contraceptive device, Oral contraceptive
Pills’ Tubectomy Vasectomy and injectable contraceptive withdrawal technique and emergency
contraception. The socio-demographic characteristics like age, parity, educational status and their income
were assessed for the awareness of the various contraceptive methods among the rural women residing in
and around Bangalore city of Karnataka state. It was found that 95 % women were aware of bilateral tubal
ligation, 85% known for condoms and 72% known for IUCD and also other various contraceptive methods.
However, lack of knowledge on their usage and attitude to the contraceptive methods, birth control is not
reaching its target.
Conclusion: The above results only reaffirms the fact that there is a gap between knowledge and practise
due lot many factors discussed in this study.

Keywords: knowledge, attitude, Practice, rural, contraception.

Introduction Govt of India along with state Governments launched a

family planning programme in 1952, with the objective
India is a home to 17% of the world’s population – a
of reducing birth rate to the extent necessary to stabilise
population of diverse cultures, languages and religions.
the population at a level consistent with requirement of
The relevance and importance of family planning
national economy. Data for India, especially regarding
in India has to be understood in the context of the
contraceptive use, are a little out of date as no nationally
burgeoning population, and the persistence of relatively
representative surveys have been undertaken following
poor social indicators in spite of a booming economy.
the third round of the National Family Health Survey
India, the second most populous country in the world,
(NFHS) – India’s DHS – in 2005–2006. Due to intense
is projected to exceed 2billion people by the turn of the
efforts to control population growth in India, the Total
twenty-first century. According to the Census of
fertility rate (TFR) has been steadily declining over
India
the past few decades. The current TFR of 2.4 in 2012
2011, the population was nearly 1.210 million, of which
is down from 3.1 children per woman in 2001, but is
31% are below the age of 15 years and 53%
still above replacement level fertility. In urban areas, the
ofwomen
TFR has reached below replacement levels at 1.8, but in
are in the reproductive age group (15–49 years)1-3.
rural areas the TFR is 2.64-5.

A typical female sterilization in India renders most

Corresponding Author: women permanently infertile. Because many women in
Dr Sudha Patil India marry in their late teens and quickly experience
Professor, Department of OBG, multiple pregnancies, women who already have two
Akash Medical College and Hospital, or
Bangalore, Karnataka State
258 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

more children and can’t care for more often opt for— Less than 50% females were accessible for primary
or are pressured into—sterilization. Women in rural and secondary education and their monthly income
and semi urban areas have no easy access to medically varies from 5 to 40%. Table-1 shows the awareness of
accurate information, high-quality healthcare from females to different contraceptive methods Viz
providers who patiently answer their questions, and no
vasectomy, natural, IUCD, condoms, bilateral tubal
clear idea of the risks and benefits of various forms of
ligation and progesterone pill were known and
birth control, and time to weigh their options and give
informed consent. Given that the reality in many parts ranges from 50 t0
of India today is that women are still being pressured or 95%. Other contraceptive methods like oral, emergency
incentivized to undergo mass sterilization. contraception were known by 30 and 2% respectively.
However, some of the contraceptive methods are poorly
In the present study, apart from the sterilization, implementing. Bilateral tubal ligation method was
other contraceptive methods known to the females in practicing by 28% women whereas other methods were
around Bangalore city were investigated.
n the range of 1 to 18% only (Table-2). The attitude of
the women for these methods was also poor and ranges
Methodology from 2 to 24% (Table 3).
This was carried out from 1st March 2018
to Table 1: Awareness of contraceptive methods
30th Dec, 2108 at Akash Medical College hospital, among the rural women in around Bangalore
Bangalore. The study was conducted in the outpatient
Methods Numbers %
clinic of Gynaecology Unit. The definition of rural was
women residing in Bangalore who have come for lively Progesterone only pills - Nil
hood from other rural places of Karnataka. The selection Bilateral tubal ligation 475 95%
criterion was married women between the ages of 15-45 Condoms 425 85%
years, living with their husbands at the time of
IUCD 360 72%
interview. Women who were pregnant, had a child
younger than 2 years or had any medical disorder were Natural 325 65%
excluded from Vasectomy 250 50%
Oral contraceptive pills 120 30%
the study. The questionnaire elicited information
regarding their age, educational status, number of Emergency contraception 10 02%
children, knowledge and source of contraceptive None 05 1%
methods, practicing of either male or female family
planning methods. The attitude of females towards Table 2: Practice of contraceptive methods among
contraception was asked, while the attitude of husbands the rural women in Bangalore
was assessed what their females perceived. To assess the
knowledge, the following 8 methods were separately Methods Numbers %
asked: pills, Injectable contraception, Intra-uterine Bilateral tubal ligation 140 28%
Contraceptive Devices (IUCDs), condoms, tubal IUCD 90 18%
ligation, vasectomy, Norplant and withdrawal method.
Natural 75 15%
The practice defines the usage of contraceptive methods
Condoms 70 14%
by either partner. Descriptive analysis was conducted to
describe the results in percentages. Oral contraceptive pills 60 12%
None 50 10%
Results Emergency contraception 05 01%

The socio-demographic characteristics like age, Vasectomy 05 01%

parity, educational status and their income were Injectables 05 01%
analysed.. The age group of 20-30 was the most Progesterone only pills Nil Nil
productive age constitutes 70%.
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 259
Table 3: Attitude of the implementation of from rural Nepal also reported an exposure to electronic
contraceptive methods among the rural women in media messages as the main factor for use of family
Bangalore planning methods among women7. An Ethiopian study
showed that 80.3% of health personnel contributed in
Reason Methods %
providing information regarding contraception, which
Wants to conceive 12 24% is opposite to the results 7. The positive aspect is that
Fear of side effects 10 20% the presently reported contraceptive prevalence rate is
Inconvenient 05 10% high with regard to knowledge, as opposed to Jordan and
Breast feeding 10 20% Nigeria where it was 31.7% and 8.7% with awareness
rate
Infrequent sex 04 8%
of 91% and 85% respectively10, 11. Regarding the usage of
Not staying together 03 06%
family planning methods, an important dimension is the
Hysterectomy 03 06% type of contraception used. Bilateral tubal ligation was
Opposed to family planning 02 04% the most common chosen method used by 28% (Table 3)
Menopausal 01 02% of couples as shown in other studies as well12, 13. Oral
pills were used by 12% of women in comparison with
32% and 10% in other areas of Pakistan 14 15. From this
Discussion study we conclude that the women were aware of most
of the contraceptive methods, but lack of
The widespread adoption of family planning, in a implementation and attitude birth control is not reaching
society, is an integral component of modern its expected results.
development and is essential for the integration of
women into social and economic life. In spite of efforts Ethical Clearance: Done from ethical committee of
exerted by the Government of India, the family AIMSRC Devanahalli bengaluru.
planning program is not yet as successful especially in
Conflict of Interest: Nil.
rural women as they are practicing the contraceptive
methods and also their attitude. Source of Funding: Self

The present study aimed to assess the knowledge,

attitude and practice of family planning methods References
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study6.Women illiteracy is one of the factor that affects glance
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and practices of contraception among Pakistani
DOI Number: 10.5958/0976-5506.2019.01574.2

Comparison Prophylactic Glycopyrrolate, Dexamethasone,

Metoclopramide in Control of Nausea and Vomiting after
Spinal Anaesthesia for Caesarean Delivery

Gautam Malhotra1, Suresh Y. V.2, Anupama Suresh Y3, Shaik Gulam Osmani4, Kavya Prabhu5
1
Associate Consultant, Sri Balaji Action Medical Institute, Paschim Vihar, New Delhi; 2Professor,
Department of Anesthesiology, 3Associate Professor, Department of Obstetrics & Gynecology,
4
Assistant Professor, 5Senior Resident, Department of Anesthesiology, Kasturba Medical College
Mangalore, Manipal Academy of Higher Education, Karnataka (India)

ABSTRACT
Background: The effects of spinal anesthesia on women in their labour period are different from those
observed in non-obstetric patients. The distribution of the anaesthetic drug in cerebrospinal fluid (CSF) is
less predictable than non-obstetric patients, Moreover side effects including hypotension, nausea and
vomiting are more common.
Aims: To compare the efficacy of inj glyocopyrolate 0.2 mg iv, inj dexamethasone 8mg i.v, inj
Metoclorpromide
10mg i.v in control of post-operative nausea and vomiting after spinal anaesthesia for caesarean delivery
Method and Material: All consenting women were explained and women were randomly allocated in to
four groups of 20 each, Group A inj.Glycopyrrolate 0.2 mg, Group B, inj. Dexamethasone 8 mg, Group C
inj. Metoclopramide 10 mg and Group D (n=20) inj. Normal saline 2m1. Level of spinal block,
hemodynemic changes, incidence of intraoperative and post-operative nausea and vomiting were noted in
all four groups. The incidences of nausea and vomiting were compared in different groups and the
differences were tested for significance by calculating ‘z’ value. A `p’ value <0.05 was considered significant.
Results: The overall (intraoperative & postoperative) incidence of nausea and vomiting which was 20% in
group A, 35% in group B, 50% in group C and 60% in group D. Statistical analysis showed that the all
three drugs decrease incidence of nausea and vomiting, but glycopyrrolte found to be more effective in
preventing nausea and vomiting.
Conclusion: The incidences of nausea and vomiting were high fallowing spinal anesthesia during
caesarean delivery. Administration of glycopyrrolate intravenously before spinal in caesarean section
effectively control the incidence and severity of intraoperative and early postoperative nausea and vomiting
compared to the non-treatment group.

Keywords: Post-operative nausea and vomiting, Spinal anesthesia, Glycopyrrolate, Dexamethasone,

Metoclopramide.

Introduction

Intra-operative and postoperative nausea and

vomiting (IONV and PONV) can be distressing to patients
Corresponding Author: undergoing Caesarean section (CS) under regional
Dr.Shaik Gulam osmani anaesthesia. The incidence of IONV are common, studies
Assistant Professor, Dept. of Anesthesiology, with rates up to 60–80% were reported.[1]
Kasturba Medical College, Mangalore.
Phone: 7019950015 Nowadays, caesarean sections account for about 7%
Email: [email protected] of all surgical procedures worldwide [2] and the majority
of
262 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 262

them are performed under spinal anaesthesia. Nausea Any patient having a history of an acid peptic
and vomiting present during the surgical procedure disease, previous history of PONV or any antiemetic
produce discomfort for the parturient, impair surgical medication, pregnancy-induced hypertension, hepatic
conditions for the gynecologist and can lead dysfunction, diabetes mellitus, and allergies to local
complications such as aspiration of gastric content.[3] anaesthetics were excluded from the study [Table/Fig-1].
PONV can lead to an increased stay in the recovery
room, nursing care, and potential hospital admission- all All patients vitals were recorded before pre-loading
with Ringer’s lactate solution 20m1/kg and this
these contribute to total health care costs[4]. Unpleasant
followed by intravenously administration of study agents
distressing experience for patient and also in severe
prior to spinal anaesthesia.
cases may cause problem such as dehydration,
electrolyte imbalance. Suture dehiscence, bleeding and Spinal anaesthesia was administered in the sitting
esophageal rupture [5]. position with 0.5% hyperbaric bupivacaine (2.2m1)
with 25 gauge Quincke’s lumbar puncture needle at
Pharmacological attempts to reduce PONV
the interspace between L3-4. After administration
include preemptive therapy with metoclopramide,
of spinal anaesthesia, women were put in the supine
dexamethasone and prophylactic use of vasopressor. [6] It
position with a 15° wedge under the right hip for left
has been reported that glycopyrrolate could successfully
uterine displacement and supplementation of oxygen 5L
minimize the incidences of PONV during neuraxial
flow per minute was administered through poly mask.
anaesthesia for a caesarean without affecting the fetal
outcome. [7] Following confirmation of spinal block by a loss of
sensation to cold and pinprick, to T4-T5 level, surgery
The aetiology of PONV in women undergoing was started and oxytocin (20 units) was administered
caesarean delivery with neuraxial anaesthesia is through intravenous infusion at the time of umbilical
multifactorial and no single intervention will eliminate cord clamping.
it completely, therefore the aim of this study is to do
the comparative evaluation, among glycopyrrolate, Assessment: Oxygen saturation, pulse rate, blood
dexamethasone and metoclopramide in preventing pressure and respiratory rate of each woman were
PONV after spinal anaesthesia in caesarean section, in recorded every 05 minutes during the surgery and post-
ASA grade I and II patients operatively every 20 minutes during the study period.
The decrease in systolic blood pressure (more than
20%of baseline value and/or less than 90mm Hg) after
Materials and Method
spinal anaesthesia was treated by increasing the rate of
After obtaining approval from institutional intravenous fluid administration and 3mg increments
scientific, ethical committee and written informed of ephedrine administered intravenously (every 3-5
consent, 80 women (American society of minutes) until resolution of hypotension.
anaesthesiologist grading I
Emetic episodes (nausea and/or vomiting)
& II, between 20 to 35 years of age) at term undergoing
experienced by women were recorded intra-operatively
caesarean delivery were enrolled for the study.
and up to 4 hours post-delivery period in the
All the consenting women were randomly allocated postoperative ward by anaesthesiologist who was
into four groups to receive: blinded to the treatment patient had received.

Groups Drugs NAUSEA is defined as an unpleasant sensation

Group A (n = 20) inj.Glycopyrrolate 0.2 mg referred to a desire to vomit not associated with
Group B (n = 20) inj. Dexamethasone 8 mg expulsive muscular movement
Group C (n = 20) Inj. Metaclopramide 10 mg VOMITING is the forceful expulsion of even a
Group D (n = 20) Inj. Normal saline small amount of upper gastrointestinal contents through
the mouth. If two or more episodes of emesis occurred
The efficacy and safety of i.v glycopyrrolate 0.2mg,
in each observation period 0-4 hrs) 4mg inj.
i.v. dexamethasone 8mg, and i.v. metocloprarnide 10mg Ondansetron intravenously was administered as rescue
were evaluated and compared for the prevention of antiemetic to the patient.
IONV and PONV in a randomized double blind placebo
controlled study[Table/Fig-1].
The incidences of nausea and vomiting were compared in different groups and the differences were tested for
significance by calculating ‘z’ value. A `p’ value <0.05 was considered significant.

Table/Fig-1: Consort diagram showing flow of participants

Results

The age, weight, ASA status, surgery duration were comparable in all group of patients and level of spinal
anaesthesia in different study groups are shown in [Table/Fig-2]. The level of spinal anaesthesia were found
statistically insignificant in association with nausea and vomiting.

Table/Fig-2: Level of spinal anesthesia in different groups:

Group A Group B Group C Group D Total
T4 N(%) 6 (30%) 10 (50%) 9 (45%) 7 (35%) 31 (38.9%)
Level T5 N(%) 7 (35%) 5 (25%) 7 (35%) 8 (40%) 27 (33.8)
T6 N(%) 7(35%) 5 (25%) 4 (20%) 5 (25%) 21 (26.3%
Total N ( %) 20 (100%) 20 (20%) 20 (100%) 20 (100%) 80 (100%)

Blood Pressure: Mean variation in SBP (111.9 mmHg) was least in group A and maximum in group D (104.5
mmHg) after spinal anaesthesia compared to other groups. But this variation in SBP was statistically insignificant
[Table/Fig-3]. So variation should not be a contributing factor for nausea and vomiting in a different group.

Table/Fig. 3: Systolic blood pressure (measured after 5 minutes of spinal anesthesia)

N Mean SD Minimum Maximum

Group A 20 111.90 13.05 90.00 130.00
Group B 20 107.00 15.16 80.00 130.00
Group C 20 104.70 14.35 80.00 130.00
Group D 20 104.70 11.90 90.00 120.00
Intraoperative Nausea and Vomiting: The incidence of intraoperative nausea which was 15%, 25% 30%
and
55% in group A, B, C &D respectively which was statistically Significant, It was lowest in the glycopyrrolate group
[Table/Fig-4]. Statistical analysis showed that the incidence of nausea in group D was significant (p<0.05) than the
other three groups. The intergroup comparison between glycopyrrolate, dexamethasone and metoclopramide
showed that all the three reduce the incidence of nausea but the antiemetic effect was least in the metoclopramide
group.

The incidence of intraoperative vomiting which was 10%, 25%, 30% and 45% in group A, B, C &D
respectively which was statistically Significant, It was lowest in the glycopyrrolate group [Table/Fig-4].Statistical
analysis showed that the incidence of vomiting in group D was significantly more (p<0.05) than the other three
groups. Two Out of three patient complaining nausea in glycopyrrolate group had vomiting, whereas in other
groups all complaining of nausea had vomiting.

Table/Fig. 4: Incidence of intraoperative (0-2hrs) nausea and Vomiting among different group
Nausea Vomiting
Present N(%) Absent N(%) Present N(%) Absent N(%)
Group A 3 (15%) 17(85%) 2 (10%) 18(90%)
Group B 5 (25%) 15(75%) 5 (25%) 15(75%)
Group C 6(30%) 15(75%) 6(30%) 15(75%)
Group D 9(45%) 11(55%) 9(45%) 11(55%)

Postoperative Nausea and Vomiting: On Comparing Incidence of postoperative nausea in four groups, group D was
50%(10/20) compared to group A, B &C which were 15%(3/20), 15%(3/20) & 30%(6/20) respectively[Table/Fig-5].
Compared to intraoperative nausea in dexamethasone group, only 3 out 5 had complained of postoperative nausea.

The incidence of postoperative vomiting in group D was 40% (8/20) compared to group A, B&C which
were
15% (3/20), 20% (4/20) & 40% (8/20) respectively[Table/Fig-4]. Statistical analysis showed that the incidence of
postoperative vomiting was high in group D but it was not significant. The intergroup comparison between
glycopyrrolate, dexamethasone and metoclopramide showed that the decrease in incidence was more in the
glycopyrrolate.

Comparing overall (intraoperative & postoperative) incidence of nausea and vomiting[Table/Fig-6].which was
20% in group A, 35% in group B, 50% in group C and 60% in group D. Statistical analysis showed that the overall
incidence was significant(p<0.05) in group D than the other 3 groups.

Table/Fig. 5: Incidence of postoperative (2-4 hours) Nausea and vomiting among different groups
Nausea Vomiting
Present N(%) Absent N(%) Present N(%) Absent N(%)
Group A 3 (15%) 17(85%) 3 (15%) 17(85%)
Group B 3 (15%) 17(85%) 4 (20%) 16(80%)
Group C 6(30%) 14(70%) 8(40%) 12(60%)
Group D 10(50%) 10(50%) 8(40%) 12(60%)

Table/Fig. 6: Total incidence of nausea and vomiting

Group A Group B Group C Group D Total

Present N(%) 4 (20%) 7 (35%) 10 (50%) 12 (60%) 33 (41.3%)
Absent N(%) 16(80%) 13(65%) 10 (50%) 8 (40%) 47(58.5%)
Total N (%) 20 (100%) 20 (100%) 20 (20%) 20 (100%) 80(100%)
Discussion review of randomized placebo-controlled studies of
18
Nausea and vomiting during neuraxial anesthesia
for a caesarean delivery are high without prophylactic
antiemetic. The hypotension due to sympathicolysis
during neuraxial anaesthesia is principle underlying
mechanisms of IONV and PONV in the obstetrical
setting. Bradycardia owing to an increased vagal tone,
the visceral stimulation via the surgical procedure,
peritoneal traction, exteriorization of the uterus and
intravenously administered opioids are other factors
contributing for nausea and vomiting [8-10]. The time of
occurrence of nausea and vomiting after general
anaesthesia for caesarean section is postoperative in
contrast to regional anaesthesia which is mainly
intraoperative.

The result of our study clearly demonstrates that

the total incidence of nausea and vomiting was 20% in
group A, 35% in group B, 50% in group C, & 60% in
group D. Data of group A, B & C were compared with
placebo group D and results in glycopyrrolate group
were found statistically significantly less than placebo
group. Comparing the incidence of nausea and vomiting
in between group it was found that the incidence of
nausea and vomiting was significantly reduced in group
A as compared to group B and group C.

Biswas BN et al. concluded the incidence of

nausea and vomiting in inj. glycopyrrolate 0.2mg group
was much less than in, inj. dexamethasone 8mg, in
metachlorpramide10mg, inj. normal saline
2m1(placebo). The total incidence of nausea and
vomiting were noted in 15% of women belonging to
glycopyrrolate as group compared 20%, 30%, 55% in
dexamethasone, metoclopramide and saline group
respectively. The p value <0.05 was considered
significant. [ 6]

D Ure et al. also concluded that Patients who

received glycopyrrolate prophylactically reported
a reduction in the frequency and severity of nausea
compared to placebo. [7]

The mechanism of action of study drug

glycopyrrolate is not clear. The antiemetic effect may be
due to the reduction in hypotension episodes because of
heart rate mediated increase in cardiac output. The results
of our study correlate with the studies mentioned above

Henzi I et al. conducted a quantitative

systematic
different regimens of metoclopramide, they found in
adults the best documented regimen was 10mg I.V. But
they concluded that 10mg metoclopramide dose was
clinically ineffective as a prophylaxis for PONV. [11]

In our study, the dosage used for metoclopramide

was also 10mg which is suboptimal for preventing
nausea and vomiting as mentioned in the above studies.
This explains the high incidence of 50% in group C as
compared to group A (20%) & B (35%).

Wang JJet al. Found that dexamethasone 8mg in

laparoscopic cholecystectomy decreased the incidence of
nausea and vomiting significantly.[12] In a Similar study,
J C Huang et al. found prophylactic
i.v.dexamethasone
5mg reduces the incidence of postoperative nausea and
vomiting in women undergoing ambulatory laparoscopic
tubal ligation, And also concluded, dexamethasone 5mg
is more effective than metoclopramide 10mg or placebo.
[13]

In our study, the incidence of nausea and vomiting

with saline was 60%. But with the administration of
dexamethasone incidence of nausea and vomiting
was (35%). Above mentioned studies show that
dexamethasone is better than saline and metoclopramide
and is effective in preventing nausea and vomiting after
gynecological surgery.

Antiemetic mechanism of dexamethasone is by

inhibiting synthesis and release of serotonin both
centrally and peripherally, by inhibiting synthesis of
prostaglandins and also by changing the permeability of
the blood-brain barrier to serum proteins.
Dexamethasone is most commonly used corticosteroid
and is integral component of almost all antiemetic
regimens in acute and delayed nausea and vomiting [14].

The aetiology of nausea and vomiting in women

undergoing caesarean section with spinal anaesthesia
is multifactorial, and no single intervention is available
to eliminate it completely, it is important to provide
adequate aspiration prophylaxis with histamine(H , 2)
dopamine receptor antagonist along with sufficient
infusion of crystalloid or colloid solutions before and
during the central neuraxial blockade to preventive
hypotension.[1] fall in blood pressure should be corrected
liberally with antihypotensive drugs such as ephedrine,
phenylephrine. Concomitant measures such as the low-
dose local anaestahetics, use of intrathecal opioids to
reduce the amount of local anesthetics needed. [15]
Although the incidence of nausea in women treated 6. Biswas BN, Rudra A, Das SK, Nath S, Biswas
with glycopyrrolate was reduced, no single antiemetic SC. A comparative study of glycopyrrolate,
drug has proved to be a universal solution to dexamethasone and metoclopramide in control
postoperative nausea and vomiting. It is not feasible to of postoperative nausea and vomiting after
give very high doses of any single drug because of spinal anesthesia for caesarean delivery. Indian J.
saturation effects and safety, so combinations of Anaesth 2003; 47(3):198-200.
antiemetic drugs are a possibility.
7. Ure D, James KS, Mcneill M, and Booth JV.
Glycopyrrolate reduces nausea during spinal
Conclusion anaesthesia for caesarean section without affecting
neonatal outcome. Br J Anaesth 1999; 82(2):277-9.
We found that although prophylactic administration
of all the three drugs decreased the incidence of nausea 8. Jelting Y, Klein C, Harlander T, Eberhart L,
and vomiting, the control of nausea and vomiting was Roewer N, Krankr p. Preventing nausea and
better with glycopyrrolate compared with vomiting in women undergoing regional
dexamethasone and metoclopramide. anesthesia for cesarean section: challenges and
solutions. Local and Regional Anesthesia 2017:10
Therefore from the results of this study, we 83–90
conclude that the administration of glycopyrrolate
9. Ishiyama T, Yamaguchi T, Kashimoto S,
intravenously before spinal in caesarean section
Kumazawa T. Effects of epidural fentanyl and
effectively controls the incidence of nausea and
intravenous flurbiprofen for visceral pain
vomiting.
during cesarean section under spinal
Ethical Clearance: Taken From Institutional Ethical anesthesia. J Anesth.
Committee 2001;15(2):69–73.
10. Wahab MA, Karantzis P, Eccersley PS, Russell
Source of Funding: Self
IF, Thompson JW, Lin- dow SW. A randomised,
Conflict of Interest: Nil controlled study of uterine exteriorisation and
repair at caesarean section. Br J Obstet Gynaecol.
1999;106(9):913–916.
REFERENCE
11. Henzi I, WalderBand.Tramer MR.
1. Balki M, Carvalho JC. Intraoperative nausea and
Metoclopramide in the prevention of
vomiting during cesarean section under regional
anesthesia. Int J Obstet Anesth 2005; 14: 230–41 postoperative nausea and vomiting: a quantitative
systematic review of randomized, placebo-
2. Weiser TG, Haynes AB, Molina G, et al. controlled studies. Br J Anaesth 1999; 83(5): 761-
Size and distribution of the global volume of 71
surgery in 2012. Bull World Health Organ.
2016;94(3):201F–209F. 12. Wang JJ, Ho ST, Liu YH, Lee SC, Liu YC, Liao
Y Cand Ho C M. Dexamethasone reduces nausea
3. Kranke P, Eberhart LH. Possibilities and and vomiting after laparoscopic cholecystectomy.
limitations in the pharmacological management
Br J Anaesth 1999; 83(5):772-5.
of postoperative nausea and vomiting. Eur J
Anaesthesiol. 2011;28(11):758–765. 13. Haung JC, Shieh JP, Tang CS, Tzeng JI, Chu KS,
and Wang JJ Low dose dexamethasone effectively
4. Macario A, Weinger M, Carney S, Kim A. Which
prevents postoperative nausea and vomiting after
clinical anesthesia outcomes are important to
ambulatory laparoscopic surgery. Can J
avoid? AnesthAnalg 2001; 92:393-400.
Anaesth
5. Ajay k, Sumith A, Puneet D. A comperative 2001; 48:973-7.
intravenous ondenseteron and palonosetron in
preventing post operative nasea and vomiting 14. Drisy AP. Emmanuel J. Recent updates in the
after laproscopic cholecystectomy a randomized managment of chemotherapy induced nausea and
double blind study. Asian J Pharm Clin Res. vomiting. Asian J Pharm Clin Res. 2013;6:5-10.
2013;11:128-31. 15. Roofthooft E, Van de Velde M. Low-dose
spinal anaesthesia for Caesarean section to
prevent spinal-induced hypotension. Curr Opin
Anaesthesiol. 2008;21(3):259–62.
DOI Number: 10.5958/0976-5506.2019.01575.4

A Study to Assess the Effectiveness of Eucalyptus Oil on Knee

Pain among Osteoarthritis Patients in Selected Areas of Sangli,
Miraj and Kupwad Corporation

Siddhant N. Shirgaokar1, Pravin Dani2

1
IInd year M.Sc. Nursing, 2Professor, Bharati Vidyapeeth, (Deemed to be University) College of Nursing,
Sangli

ABSTRACT
Background: Osteoarthritis is a progressive disease that occurs due to age and deterioration of joint
health thus leading to pain in the joints. It is one of the primary causes for pain and disability across the
globe. Osteoarthritis is mainly treated with pharmacological interventions such as NSAID’S. Persistent
use of NSAID’S may have adverse effects on multiple essential organs thus exposing the patient to further
complications.
Objectives: 1. To assess the level of knee pain among osteoarthritis patient. 2. To assess the effectiveness
of Eucalyptus oil application on level of knee pain among osteoarthritis patients.
Methodology: Quasi-experimental pre-test post-test control group design was directed to assess effect of
eucalyptus oil application on knee pain among osteoarthritis patients in selected areas. Total 100 samples
were selected by non-probability purposive sampling method, (50 experimental group and 50 non-
experimental group). A modified Allina pain scale was used to assess the level of knee pain among the
osteoarthritis patients. The study adopted the “General System theory” as a theoretical base for framework
of the study. Analysis was done using frequency and percentage distribution and ANNOVA test.
Result: The mean pain score in the experimental group on day one was 6.82, on the third day it was 5.66
and on day seven it was 4.42. The mean pain score on day one was 5.72, on the third day it was 5.42 and on
day seven it was 5.34. Variation was found in the mean and SD scores in experimental and control group .p
value is less than 0.005.The statistical data shows a variation in mean score of knee pain among
osteoarthritis patients in experimental and control group.
Conclusion: Thus it was concluded that, on the basis of statistical tests, eucalyptus oil application
was
efficient in minimizing knee pain in the experimental set.

Keywords: Effect, eucalyptus oil, knee pain, osteoarthritis

Introduction place as the commonest problem related to

rheumatology and is the most commonly occurring
Osteoarthritis (OA) is the disorder related to the
illness, in India the incidence rate is of 22% to 39%.
degeneration of joints, and it occurs frequently in daily
About 45% of women who are above the age of 65 years
practice, it is one of the primary causes for disability in
have symptoms, and radiological proof of the disease is
the elderly.[1] In all of the rheumatic diseases which are
found in 70%.[2] Osteoarthritis Is a disease which is of a
chronic in nature, the osteoarthritis of the hip and the
huge challenge because of the less number of options
knee is the most common one. Osteoarthritis stands in
to treat it with. Regular treatment and therapy such
second
as acetaminophen,
NSAIDs, and opioids are helpful to reduce the intensity
Corresponding Author: of pain but they are not able to reverse the progression
Mr. Siddhant N. Shirgaokar of the disease and may even cause adverse effects.[1]
Bharati Vidyapeeth (Deemed to be University) Non steroidal anti-inflammatory drugs (NSAIDs) are
College of Nursing, Sangli-416416 one of the most frequently used type of drug around the
Email: [email protected] globe. Their main effect is that of reducing inflammation
268 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 268

and reducing pain in the person consuming them. On z Explain the intent and how he/she has to cooperate.
the flip side this medicine is potentially harmful as it
z Clean the knee with a cotton pad
increases the risk of cardiovascular and gastrointestinal
complications. NSAIDs affect the upper and lower gut z Apply 0.25ml eucalyptus oil on the effected knee.
by harming the mucosa and thus causing topical injury
Post intervention phase: The level of effectiveness on
{3}
Eucalyptus essential oil is a derivative of the
knee pain was assessed with the help of Modified Allina
eucalyptus tree.[4] Eucalyptus oil has a variety of
Pain Scale after application of eucalyptus oil in both
medicinal benefits thus unsurprisingly it is a widely used
experimental and control group on the 1st day, 3rd day
product. It is used as an anti-inflammatory, anti-
and 7th day one hour after the application
spasmodic, anti-congestive, disinfectant, antibacterial
and antiseptic agent.[4] An ethical clearance was obtained from the
institution and informed consent was obtained from the
Materials and Method participants, samples were selected using the purposive
sampling technique. The following hypotheses were
The Quasi-experimental research design- pretest & formulated for the study
post test control group design, was adopted to conduct
the study. The main purpose of the study was to assess Hypothesis
the effect of eucalyptus oil application on knee pain H0: There is no effect of Eucalyptus oil application
among osteoarthritis patients. The sample size consists on
of knee pain among osteoarthritis patients.
100 osteoarthritis patients, Out of 100 samples 50 were
selected for experimental group and 50 were selected H1: There is effect of Eucalyptus oil application on knee
for control group. General demographic variables and pain among osteoarthritis patients.
the modified Allina pain assessment scale [6] were used
as the tool to gather the data. This scale shows reading
Statistical Analysis
from 1-10. From 1-3 there is mild pain, from 4-6 there is
moderate pain and from 7-10 there is severe pain. Descriptive Statistics: Frequency and percentage
distribution were used to analyze the socio-demographic
Data Collection was Done in Following Steps data.

Procedure for data collection Inferential Statistics: Annova test was used to compare
the data within the groups on the 1st, 3rd and 7th day.
1. Pre intervention phase: Osteoarthritis patients
as per the criteria were picked and permission Results
was obtained from selected patients after briefing
the patient about the study. Gathering and Assessment of level of knee pain before
documentation of the Demographic data was administration of eucalyptus oil in Experimental &
done. Determination of the level of pain was done Control Group
by using the Modified Allina Pain Assessment
Scale in both groups. Table 1: Assessment of level of knee pain before
administration of eucalyptus oil in Experimental
2. Intervention phase: In experimental group,
& Control Group
eucalyptus oil application was done twice a
day for 7 days straight. In control group routine
N = 100
checkup was followed. Experimental
Control Group
Steps of intervention: Group

Articles: Pain (Day 1)

Frequency

Percentage

Frequency

Percentage

z Eucalyptus oil
z Modified Allina Pain Scale Paper scale
Mild 1-3 0 0.00 0 0.00
z Cotton pad.
Moderate 4-6 17 34.00 38 76.00
Procedure: Severe 7-10 33 66.00 12 24.00
z Explain the procedure to patient.
Assessment according to level of knee pain before administration of eucalyptus oil, 34% were in moderate
category and 66% in the severe and no one in the mild knee pain category in experimental group. According to level
of knee pain on day 1 without administration of eucalyptus oil, 76% were in moderate categor y, no one in the mild
and 24% in severe knee pain category in control group.
z Analysis of data related to the effectiveness of Eucalyptus oil application on level of knee pain among
osteoarthritis patients in experimental and control groups.

Table 2: Knee pain before and after the application of Eucalyptus oil in Experimental Group
N = 50

Groups N Mean df F cal value F table value p value Significance

Day 1 50 6.82
Day 3 50 5.66 2,147 39.39 3.06 0.00 Significant
Day 7 50 4.42

The above table shows the comparison of knee pain prior and after the application of the eucalyptus oil in the
experimental group. The mean pain score on day one was 6.82, on the third day it was 5.66 and on day seven it was
4.42. The ‘p’ value is 0.00 thus rejecting the null hypothesis.

Table 3: Knee pain without application of Eucalyptus oil in Control Group

N = 50

Groups N Mean df F cal value F table value p value Significance

Day 1 50 5.72
Day 3 50 5.42 2,147 1.29 3.06 0.28 Not Significant
Day 7 50 5.34

The above table shows the comparison of knee pain in the control group. The mean pain score on day one was
5.72, on the third day it was 5.42 and on day seven it was 5.34. The ‘p’ value is 0.28 for this table.
z Comparison of knee pain in Experimental and Control Group

Table4: Comparison of knee pain in Experimental and Control Group

N = 100

Group (day 7) Frequency Mean S.D. t value P value

Experimental 50 4.42 1.26
3.58 0.001
Control 50 5.34 1.30

The comparison of the average knee pain score of Discussion

the experimental and control group after 7 days was
done by the unpaired t test. The average knee pain The findings in the study as per shows that in the
score of experimental group was 4.42 with standard experimental group the maximum population was
deviation of from the age group of 51-60 years (40%) while in the
1.26. The average knee pain score of control group was control group, the maximum population was also in
5.34 with standard deviation of 1.30. The test statistics the age group of 51-60 years (54%). Age is one of the
value of the unpaired t test was 3.58 with p value 0.001. primary reasons of risk to contract osteoarthritis. The
This shows that there was significant difference in the increase of incidence of people facing osteoarthritis
average knee pain score at 5% level of significance is
due to the addition of many different factors, physical The findings presented in [Table No-4] shows us
and physiological factors that occur with the process the comparison of knee pain between the experimental
of aging, thus making the joint less able to cope with and control group. The mean pain score on the first day
various changes and pressures `applied on it [7]. in the experimental and control group is 6.82 and 5.72
respectively with a standard deviation of 1.26 and 1.21 in
In the gender criteria, most participants were the experimental group and control group respectively.
females (70%) as compared to males (30%). In the The mean pain score on day 3 in the experimental and
duration of disease criteria. The readings were found control group is 5.66 and 5.42 respectively with the
consistent with a study conducted on Epidemiology of standard deviation for the experimental and control
knee osteoarthritis in India and related factors, group being
Osteoarthritis of the knees is found to be more common 1.52 and 1.23 respectively. The mean pain score on the 7
th

in females as compared in males. This finding was day for experimental and control group is 4.42 and 5.34
found statistically significant. [2] respectively with the standard deviation for experimental
and control group being 1.26 and 1.30 respectively.
The maximum samples (40%) in the experimental
group had the knee pain since 2 years and in the The findings of the study were compared
statistically, it was found that the study findings were
control group the maximum samples (36%) are facing
consistent with the study conducted by Mr. Yang Jun,
the ailment for more than 5 years. The readings were
(Et al); Seoul assessed the effectiveness of eucalyptus oil
consistent with a study conducted on Knee pain and
on pain in the knee and swelling after total knee
health-related quality of life among older patients with replacement.[10] Which showed that eucalyptus oil was
different knee osteoarthritis severity in Saudi Arabia. In effective on knee pain
this, the patients with knee osteoarthritis for an average
of 7.5 years severe to moderate knee pain than those The findings of this study were consistent with
with mild to moderate knee osteoarthritis for an average another study conducted by Mr. Basil Varghese;
of 4 years. [8] Mandya on the effectiveness of eucalyptus oil on
knee pain reduction in osteoarthritis patients. Which
All the samples (100%) in both the experimental also showed that eucalyptus oil is competent to
and control group were prescribed pain medications minimize pain of the knee among osteoarthritis patients.
[11]
for their pain. The findings were found consistent with
a study conducted by on Non-surgical treatment of
osteoarthritis-related pain in the elderly showed that, Delimitations and Recommendations
doctors rely heavily on NSAIDs to treat the pain faced
This study is delimited to men and women
in osteoarthritis. Acetaminophen is the choice of drug
diagnosed with osteoarthritis of the knee, with the
in the initial stages due to its comparative safety. Thus
subjects who are having moderate to severe pain only
prescribing medications to deal with the pain faced by
being included.
osteoarthritis patients. [9]
1. Comparative studies can be done for testing both
The findings presented in [Table No-2] shows the the difference between pharmacological treatment
comparison of knee pain prior and after the application and treatment with eucalyptus essential oil
of the eucalyptus oil in the experimental group. There 2. A comparative research could perhaps be done on
are three total readings taken, i.e. on day 1, day 3, and a bigger specimen range along with a prolonged
day 7. The mean pain score on day one was 6.82, on the time span thus the findings can be relatable to a
third day it was 5.66 and on day seven it was 4.42. The bigger community.
‘p’ value is 0.00 thus rejecting the null hypothesis.
3. A parallel analysis could perhaps be executed to
The findings presented in [Table No-3] shows the analyze the effectiveness of eucalyptus oil on joint
comparison of knee pain in the control group on the 1 st pain in other bone diseases
day, 4. A contrastive study could perhaps be done to
3rd day and 7th day of observation. The mean pain score on analyze knee joint pain between men and women
day one was 5.72, on the third day it was 5.42 and on day suffering from osteoarthritis.
seven it was 5.34. The ‘p’ value is 0.28 for this table.
5. A identical analysis could be carried out to
evaluate the effectiveness of other essential oils
with anti-inflammatory properties on pain among
osteoarthritis patients.
Conclusion 4. Kiran Patil, 18 wonderful benefits of eucalyptus
oil, October 23,2018, https://www.organicfacts.
In the present study, the effectiveness of eucalyptus
net/health-benefits/essential-oils/health-benefits-
oil application on knee pain among osteoarthritis
of-eucalyptus-essential-oil.html]
patients was assessed. Eucalyptus oil with its anti-
inflammatory properties helps in alleviating pain. It is 5. Up Nature, Top 20 incredible benefits of
concluded that the use of eucalyptus oil for knee pain eucalyptus essential oil, March 16, 2017,
among osteoarthritis patients is a safe, cheap and [https://www. up-nature.com/blogs/news/top-
effective method to decrease the pain among 20-incredible- benefits-of-eucalyptus-essential-
osteoarthritis patients having knee pain. oil]

Conflict of Interest: Column is Nil. 6. Allina Health’s Patient Education Department,

Managing Your Pain, 2016 https://wellness.
Source of Funding: Self. allinahealth.org/library/content/0/10

Ethical Clearance: Proposal of research with the data 7. Yuqing Zhang and Joanne M. Jordan,
collection tool was presented in the front of research Epidemiology
ethical committee for approval. Informed written of Osteoarthritis, clinics in geriatric medicine,
consent from each participant was taken. Which 2010August;26(3): 355–369, [https://www.ncbi.
included name, number, organization, time duration of nlm.nih.gov/pmc/articles/PMC2920533/]
participation, termination of participation, purpose of the 8. Saad M. Bindawas, Vishal Vennu, (et.al), Knee
study, incentives, benefits, and where it was promised pain and health-related quality of life among older
that there will be no risk to the clients. Principle of patients with different knee osteoarthritis severity
confidentiality was attained by giving code number to in Saudi Arabia., 2018 May 15, [https://www.
data collection tool. The received information also kept ncbi.nlm.nih.gov/pmc/articles/PMC5953496/]
confidential. Ethical clearance is done obtained under
9. Saulat Mushtaq, Rabeea Choudhary and
the chairmanship of Dr. Sripriya and Dr. Nilima Bhore.
Carla R. Scanzello, Non-surgical treatment of
osteoarthritis-related pain in the elderly, 2018 Jun
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1. Wei Zhang, Hongwei Ouyang, Current research gov/pmc/articles/PMC3261252/]
on pharmacologic and regenerative therapies for
10. Yang Suk Jun, Purum Kang, Sun Seek Min,
osteoarthritis, Bone Reaserch, Mar 2016:4:15040
Effect of Eucalyptus Oil Inhalation on Pain
[https://www.ncbi.nlm.nih.gov/pmc/articles/
and Inflammatory Responses after Total Knee
PMC4772471/]
Replacement: A Randomized Clinical Trial,
2. Chandra Prakash Pal, Pulkesh Singh, (et. al.), Evidence-Based Complementary and Alternative
Epidemiology of knee osteoarthritis in India and Medicine,2013,Article ID 502727, 7 pages,
related factors, IndianJournal of Orthopedics, [https://www.ncbi.nlm.nih.gov/pmc/articles/
2016Sep;50(5):518-522. [https://www.ncbi.nlm. PMC3703330/]
nih.gov/pmc/articles/PMC5017174/]
11. Basil Varghese, “A Quasi Experimental study to
3. Sostres C, Gargallo CJ,(et.al.), Adverse effects of assess the effectiveness of eucalyptus oil massage
non-steroidal anti-inflammatory drugs (NSAIDs, on pain reduction among osteoarthritis patients
aspirin and coxibs) on upper gastrointestinal tract, who have got admitted in selected hospitals in
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DOI Number: 10.5958/0976-5506.2019.01576.6

A Study to Assess the Knowledge Regarding Self-Care

Management among the Pregnant Mother with PIH Attending
Selected Maternity OPD’s of Tertiary Hospitals in Sangli,
Miraj and Kupwad Corporation Area

Silviya John Gaikwad1, Vijaya Kumbhar2

1
M.Sc Nursing, 2Associate Professor, Bharati Vidyapeeth (Deemed to be University), College of Nursing
Sangli, Maharashtra

ABSTRACT
Pregnancy is absolutely one of the most pleasurable experiences in a women’s life. Pregnancy may be
natural, but it does not mean that it is a problem free. 4 PIH is characterized by high blood pressure and the
presence of proteinurea accompanied by edema that has a harmful effect equally on both fetus and mother
adversely.5 The purpose is to assess the knowledge regarding self care management and to find the
association between knowledge score with selected demographic variables among the mothers with
pregnancy induced hypertension. The study was conducted by using quantitative approach with non-
experimental, explorative, descriptive research design. The conceptual framework was based on self care
theory, developed by Dorothea Orem.18 The reliability was calculated by using Karl Pearson’s formula
coefficient. Total 120 samples were selected by Probability simple random sampling technique, lottery
method. Data collection tool had knowledge questionnaire to assess knowledge regarding self-care
management of PIH. It was found that 62.50% of mothers with PIH were having poor knowledge regarding
self care management of PIH. Thus it was concluded that implementation of knowledge regarding self care
management of PIH would be beneficial to mothers having PIH in many ways like it reduces the further
complications.

Keywords: Assess, knowledge, mothers with PIH, self care management

Introduction on both fetus and mother adversely. 5 PIH particularly
preeclampsia is a key source of maternal and perinatal
Pregnancy is absolutely one of the most pleasurable
morbidity and mortality worldwide.6 The national
experiences in a women’s life.4 The news of pregnancy
occurrence of PIH ranges in between 5-15.2% in India.9
excites the women; she plans everything for the arrival
However hypertensive disorders in pregnancy cannot be
of the new baby with a lot of care and happiness.2
arrested and progress of complications can be barred by
Pregnancy may be natural, but it does not mean that
timely detection and eminence self care management
it is a problem free.4 On the other hand a lot of health
of PIH mothers at home.7 The components of self care
disorders are acknowledged to make this memorable
management of mothers with PIH includes rest and
moment difficult and the most imminent one is
sleep, positioning, exercise, stress management, weight
Pregnancy Induced Hypertension. PIH is characterized
monitoring, fetal monitoring, recognition of sign and
by high blood pressure and the presence of protein
symptoms of complications and frequency of antenatal
in urea accompanied by edema that has a harmful effect
checkups, which help the mother to reduce PIH and take
equally
prompt action in case of emergency in order to
reduce
the incidence of maternal morbidity and mortality.
Corresponding Author:
Mrs. Vijaya Kumbhar,
Aim
Associate Professor
Bharati Vidyapeeth (Deemed To Be University) To assess the knowledge regarding self care
College Of Nursing Sangli-416416, Maharashtra management and to find the association between
273 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 273

knowledge score with selected demographic variables questionnaire to assess knowledge regarding self-care
among the mothers with pregnancy induced management of PIH.
hypertension.

Assumptions: Mothers with PIH may have some Results

knowledge regarding self-care management.
Section II: Frequency and percentage distribution of
knowledge score.
Materials and Method
Table 1: Frequency and Percentage Distribution of
A present study was conducted by using quantitative Knowledge Score
approach with non-experimental, explorative, N = 120
descriptive research design. The conceptual framework
was based on self care theory, developed by Dorothea Knowledge Score Frequency Percentage (%)
Orem, with the concept of theory containing self care, Poor (0-6) 75 62.50
self care agency, therapeutic self care demand, self care Average (7-12) 43 35.83
requisites. The reliability was done by using split half Good (13-17) 2 1.67
method ‘r’ was calculated by using Karl Pearson’s
Table No. 2 indicates that in knowledge scores,
formula coefficient ‘r’ of the questionnaire was0.77.
62.50% of mothers with PIH were having poor
Validity was done from 15 experts, out of which 11 had
knowledge, 35.83% were having average knowledge
received. Proposal with tool presented in front of ethical
and remaining 1.67% mothers with PIH were having
committee for permission. Total 120 samples were
good knowledge.
selected by Probability simple random sampling
technique, lottery method. Pilot study was conducted Section III: Association between knowledge score with
with 12 samples and the study was found feasible. selected demographic variables.
Final study was conducted with same data collection
tool. Data collection tool had knowledge

Table 2: Association between Knowledge Score with Selected Demographic

Variables N = 120

Sr. Knowledge Chi p

Variable d. f. Significance
No. Poor Average Good Square value
1. < 20 7 2 0
21-25 32 17 0
Age in years. 13.53 6 0.035 Significant
26-30 28 16 0
31-35 8 8 2
2. Informal 20 3 0
Primary 22 14 0
Education 13.82 6 0.032 Significant
Secondary 19 14 0
Higher 14 12 2
3. Housewife 50 30 0
Occupation Private 21 10 0 25.46 4 0.000 Significant
Government 4 3 2
4. Family below 5000 25 17 2
Not
Income in 5001-10000 24 18 0 7.04 4 0.134
Significant
Rs.
above 10001 26 8 0
Table 3: Association between Knowledge Score with Selected Demographic
Variables N = 120

Sr. Knowledge Chi d. p

Variable Significance
No. Poor Average Good Square f. value
5. Primigravida 41 23 1 Not
Gravid 0.03 2 0.985
Multigravida 34 20 1 Significant
6. 20-24 21 10 0
Gestational age in 25-28 39 26 0
26.41 6 0.000 Significant
weeks 29-32 11 4 0
33 & above 4 3 2
7. Family history of Yes 50 31 2 Not
1.28 2 0.527
hypertension No 25 12 0 Significant
8. Previous knowledge Yes 30 20 1 Not
0.52 2 0.771
regarding PIH No 45 23 1 Significant
9. Friends and family
12 10 0
members
Source of Mass Media 3 4 1 Not
10.49 6 0.105
information Significant
Health personal 6 5 0
Books 9 1 0
The data in table No. 4 and Table No. 5, represented Section II: Assessment of knowledge in terms of
that there was significant association between age in frequency and percentage
years, education, occupation and gestational age in
Data of the mothers with pregnancy induced
weeks with knowledge score as the calculated ‘p’ value
hypertension was analyzed to assess the knowledge,
is less than tabulated ‘p’ (0.0) value. It also indicates that
regarding self care management in terms of frequency
there was no significant association between family
and percentage.
income in Rs. gravid, family history of hypertension,
previous knowledge regarding PIH and sources of In knowledge scores, 62.50% of mothers with
information with knowledge score as the calculated ‘p’ PIH
value is more than tabulated ‘p’(0.0) value. were having poor knowledge.

Section III: Association between knowledge score

Discussion with selected demographic variables.

Section I: As per the analysis of the study finding it was The chi-square test was used to find out the
found that most of the mothers with PIH (40.83%) were association between knowledge score with demographic
between the age group of 21-25 years, 27.50% mothers variables. In age in years of mothers with PIH ‘p’
with PIH were secondary educated, 66.67% mothers value was 0.035 which is less than 0.05 so there is a
with PIH were housewife, 36.67% mothers with PIH significant association between age of mothers with PIH
were from a monthly family income group below Rs. with knowledge score. In education ‘p’ value was 0.033
which is less than 0.005 so there significant association
5000/-
between the education of PIH mothers with knowledge
, 54.17% were primigravida mothers, 54.17% were in
score. In occupation ‘p’ value was 0.000, which is
between the 25-28 weeks of gestation, 69.17% mothers
less than 0.05 so there significant association between
with PIH had a family history of hypertension, 57.50% the occupation of PIH mothers with knowledge score.
mothers with PIH had no previous information regarding The ‘p’ value between gestational age in weeks and
self care management of PIH, 43.14% mothers with PIH knowledge score was 0.00, less than 0.05 so there is
got the information regarding self care management of significant association between gestational age in weeks
PIH from friends and family members. with knowledge score.
The findings of the present study have been Planning for implementation of knowledge regarding
discussed self care management of PIH would be beneficial to
with reference to the objectives and assumption. the PIH mothers and reducing the chance of further
complications.
The study results were consistent with the research
conducted by Tanya Salim et al in Trivandrum; Kerala The findings of the study recommended that can be
assessed the knowledge of gestational hypertension and conducted on larger populations, in different settings,
its self care management among primigarvida women. among the nurses and by using an observational
Non-experimental, descriptive research design was used checklist to assess practices.
for the study. The subjects were 240 primigravida women
selected by using consecutive sampling technique. A Conflict of Interest: Nil.
semi structured interview schedule was used to collect
Source of Funding: Self.
data from the patients. The results showed that 70.7% of
pregnant women had poor knowledge and only 4.2% had Ethical Clearance: Proposal of research with the data
good knowledge regarding gestational hypertension. collection tool was presented in the front of research
36.4% of pregnant women had poor knowledge and committee for approval. Prior permission from hospitals
26.4% had good knowledge regarding its self care
was taken. Informed written consent from each
measures. Significant association was noted between
participant was taken which included name, number,
knowledge of gestational hypertension and age and
organization, time duration of participation, termination
education of pregnant women. There is a significant
of participation, purpose of the study, incentives,
association of knowledge of self care measures of
benefits, and where it was promised that there will be no
gestational hypertension with age, place of residence,
risk to the clients. Principle of confidentiality was
educational status and use of mass media as a source of
attained by giving code number to data collection tool.
information.
The received information also kept confidential. Ethical
clearance was done with the committee members Dr.
Conclusion
Sripriya and Dr. Nilima Bhore mam.
It gives brief description of study as well as
summary and the outcome of the study. It also gives REFERENCES
appropriate implications and recommendations for
1. M. Munirathnamma, T. Lakshmamma.
further research study.
Knowledge of staff nurses regarding management
The main aim of the study was, to assess the of pregnancy induced hypertension (PIH).
knowledge regarding self care management among the International Journal of Humanities & Social
mothers with PIH. The design used for the study was Science invention. 2013 November; 2(11) :8-12
non experimental, explorative, descriptive research
2. Reddy B., Williams E. Optimal treatment of
design. The study was conducted at selected maternity
minor ailments in pregnancy requires careful
OPD’s of tertiary hospitals in Sangli, Miraj and Kupwad
evaluation of the risk and benefit. Pharmacy in
corporation area. The Sample size of the study was 120
PIH mothers. practice. 2009 September:81-84
3. Parmjit Kaur, Mr. Jibin Varghese. A descriptive
The reliability of the tool was determined Split Half
study to assess the knowledge and attitude on
Method of Reliability, the tool was administered to 12
birth preparedness among primigravida mothers
samples. Reliability of the tool was found to be 0.77.
attending gynec OPD at selected hospital Patiala,
The pilot study was conducted, to assess the Punjab. Asian Journal Of Nursing Education And
feasibility of the study and to decide the statistical Research. 2018. 8(1):106-110.
analysis and practicability of research. It was found
4. Adele politer, et al., Textbook for maternal and
feasible.
child health nursing. 4th edition. Wippincon
Finding of the present study revealed that William. New York. 2002: 404-410
significant amount of PIH mothers were lacking
the knowledge about self care management of PIH.
5. Muhammed Safvan, Namitha B. R, Neetha, 11. Tesfaye Abera Gudeta, Tefera Belachew
Nimitha Cyriac, Pramila, Gracy Silvester. The Lema, Sena Belina KItila. Pregnancy induced
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multifactorial disease. Disease Models And primary health care centers at Kirkuk city. Kufa
Mechanisms. 2012. 5: 9-18. Journal For Nursing Sciences. 2016 August.
7. Tanya Salim, Annamma Kuriakose. Knowledge 6(2):1-10.
of gestational hypertension and its self care 13. Pramitha P. Compare knowledge on self care
measures among primigravid woman. Journal management of PIH between primigravida and
Of Medical Science And Clinical Research. 2017 multigravida. Nitte University Journal Of Health
January. 5(1): 15328-15335. Science. 2014 September. 4(3):61-65.
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Notion, Donewell Bangure and Prosper Chonzi. Thimmaraju, Ayaz K. Mallick, Kanchan Dalmia,
Prevalence of pregnancy induced hypertension Biswajit Das. Socio-demographic profile of
and pregnancy outcomes among women seeking pregnancy induced hypertension in a tertiary
maternity services in Harare, Zimbabwe. BioMed care centre. Scholars Journal Of Applied Medical
Central Cardiovascular disorders, 2015 (15): 111 Sciences. 2014. 2(6D):3081-3086. Available from
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Khattak, Rizwan Bashir Kiyani. Impact of 15. Sarker Shamina Ahmed, Nazma Sultana, Most
pregnancy induced hypertension on birth weight Luthy Begum, Lobaba Sultana Lima, Md Firoz
of newborn at term. Journal Of Rawalpindi Abedin, Md Kausar Hosen. Pregnancy induced
Medical College.2011;15(2):113-115. hypertension and associated factors among
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DOI Number: 10.5958/0976-5506.2019.01577.8

A Study to Assess the Relationship between Job Satisfaction

and Burnout among Staff Nurses Working in Selected
Hospitals of Sangli, Miraj and Kupwad Corporation Area

Umesh Kisan Rathod1, Satish Salvi2

1
M.Sc Nursing, 2Associate Professor, Bharati Vidyapeeth (Deemed to be University), College of Nursing
Sangli, Maharashtra

ABSTRACT
Registered nurses (RNs) are the largest healthcare industry. Despite several rewards to care for a
profession, there are many tensions that affect the nurse.1 The emotional dimension of the nursing work
environment provides new insights into the burning experience. Approximately 30% to 50% of work
increases the workload burden, which leads to professional pressure.2 The effect of burnout is intense Nurse
Job satisfaction is combined with performance and quality care. The purpose is to assess the level of job
satisfaction, level of burnout and to find the association between job satisfaction and burnout among staff
nurses13. The study was conducted by using quantitative approach with non experimental, explorative,
descriptive research design. The conceptual framework was based on job demand control model developed
by Karasek 1979. 110 staff nurses were selected through non probability convenient sampling technique.
Data collection tool was standards tool-maslach burnout inventory (BMI) and The Benjamin Rose nurse’s
assistant job scale is an 18 item scale or instruments. It was found that 80.91% of professional burnout
scores were less than burning. 90.91% of nurses have a low level of personality crash. 48.18% of staff and
nurses were less fuelled. 57.27% nurses were satisfied with the assessment of employees’ well-being.
There is no significant link between work and work satisfaction among employee nurses.14
There is no significant connection between the disturbances of employee nurses and work satisfaction.
There is a significant connection between employee record and job satisfaction. The study concluded that
the key findings of work and job satisfaction studies from workforce and nurses. 90.09% nursing
personality disorder and 57.27% nurses are satisfied. In addition, the association showed that among the
staff and nurses in the data there is a significant difference between burning and job satisfaction.8

Keywords: Assess, job is satisfied, burnout, employee

nurse
Introduction fatigue.8 Depression affects nearly every aspect of
A. Burned Out: Burn syndrome (BOS) was found human life, however Bose also has overall health.
in human service specialists in the early 1970s. It Maslach reduces and Jackson Maslach Burnout
can be described as a way to prevent emotional Invoice (MBI) survey and the intensity of species
stress in jobs, or to exacerbate the use of energy of mammals. Factors that determine working
and resources that lead to feelings of failure conditions and workloads in workplace syndrome13
and B. Job Satisfaction: Nurse Job satisfaction has
been coupled to performance and to providing
quality nursing care. There have been extensive
studies in the USA and Europe on nurse’s
Corresponding Author:
job satisfaction and to some extent in Asian
Mr. Satish Salvi countries like Japan, Korea and Taiwan. 13This
Associate Professor study can investigate the amount of satisfaction
Bharati Vidyapeeth (Deemed to be University) among non public hospital nurses and also the
College of Nursing Sangli- 416416 Maharashtra factors with that there glad or discontented.
Email: [email protected]
278 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Aim received. Proposal with tool presented in front of ethical

committee for permission. 110 staff nurses were selected
To assess the level of job satisfaction, to assess the
through non probability convenient sampling technique.
level of burnout and to find the association between job
Pilot study was conducted on 12 staff nurses and the
satisfaction and burnout among staff nurses.
study was found feasible. Final study was conducted
Assumption with same data collection tool. Data collection tool was
standards tool-maslach burnout inventory (BMI) and The
There may be relationship between job satisfaction Benjamin Rose nurse’s assistant job scale is an 18 item
and burnout among staff nurses. scale or instruments.
Materials and Method Result
The present study was conducted by using Section I: Assessment of Level of Job Satisfaction
quantitative approach with non experimental, in Terms of Frequency and Percentage: Deals with
explorative, descriptive research design. The conceptual analysis of data related to assessment of the level of
framework was based on job demand control model burnout among staff nurses in terms of frequency and
developed by Karasek 1979. Validity was done from percentage.
30 experts out of which 25 had

Table 1: Assessment of the Level of Burnout–Burnout

N = 110
Variable Burnout Scores Frequency Percentage
Low level < 17 89 80.91
Burnout Moderate 18-29 21 19.09
High > 30 0 0.00

The above table shows, the assessment of the burnout of the staff nurses at the work places, in burnout scores
80.91% of staff nurses were having low level of burnout, 19.09% were moderate level burnout and no one in the high
level burnout.

Section II
Deals with analysis of data related to assessment of the level of Job Satisfaction among staff nurses in
terms of
frequency and percentage.

Table 2: Assessment of the Level of-Job Satisfaction

N = 110
Variable Group Scores Frequency Percentage
Very Dissatisfied 0 -14 0 0.00
Dissatisfied 14-27 18 16.36
Job Satisfaction
Satisfied 28-41 63 57.27
Very Satisfied 42-54 29 26.36
The above table shows, the assessment of the job satisfaction of the by the staff nurses, concludes that 57.27%
of staff nurses were satisfied with their job, 26.36% were in very satisfied group, 16.36 were dissatisfied and no one
in the very dissatisfied group.

Section III

Deals with analysis of data related to the association between job satisfaction and burnout among staff nurses.
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 279
Table 3: Association between Job Satisfaction and Burnout among Staff Nurse
N = 110
Job Satisfaction
Chi p
Variable Groups Very d. f. Significance
Dissatisfied Satisfied Square value
Satisfied
Low level 17 50 22
Burnout Moderate 1 12 7 2.71 2 0.258 Not Significant
High 0 0 0
Low level 17 56 27
De
Moderate 1 7 2 0.75 2 0.68 Not Significant
personalization
High 0 0 0
Low level 6 2 15
Personal
Moderate 1 16 7 10.55 4 0.032 Significant
Achievement
High 11 15 7

Discussion Pilot study is a trial study carried out before a

research design is finalized to assist in defining the
Most researchers and nurses are aged 18-24, that
research question or to test the feasibility, reliability and
is, 39.09%, the population and nurses are experienced
by women, namely 64.55%, and the eligibility criteria validity of the proposed research design.
that the population and nurses experience ANM 35.45%.
Conflict of Interest: Column is Nil.
Most nurse workers refer to age 90.00, 87 in 87 nurses at
ICU, i.e. 79.09%, the maximum nursing monthly income Source of Funding: Self.
is between 1000-1-15000 rupees, i.e., the marriage rate
indicates a maximum of 70.91% of marital Ethical Clearance: Proposal of research with the data
marriages. collection tool was presented in the front of research
44.55% No children, 73.64% of nurses are supported by committee for approval. Prior permission from hospitals
members, and 55.45% of family members are nursing were taken. Informed written consent from each
parents the shows.
participant was taken. Which included name, number,
During the assessment of employees’ burning organization, time duration of participation, termination
estimates, 90.09% nurse staff showed that the personality of participation, purpose of the study, incentives,
disorder and 57.27% nurse workers were satisfied. In benefits, and where it was promised that there will be no
addition, the information received from the union showed risk to the clients. Principle of confidentiality was
that there was no significant difference between job loss attained by giving code number to data collection tool.
and job satisfaction between employees and nurses. The received information also kept confidential. Ethical
clearance is done with the committee members Dr.
Conclusion Sripriya and Dr. Nilima Bhore mam.

An analysis of the relationship between job

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DOI Number: 10.5958/0976-5506.2019.01578.X

A Study on Awarness among Employees on Health Care and

Appraisal System Adopted in Pharmacy Companies

S. Poongavanam1, S. Jivita2
1
Associate. Professor, 2Research Scholar, AMET Business School, AMET University,
Chennai

ABSTRACT
Performance appraisal has been defined as any personal decision that affects the status of employee
regarding their retention, termination, promotion, transfer, salary increase or decrease or admission into a
training programme. This study focuses on corporate training give by the company and how it has its
impact on the changing business scenario. Data are collected through questionnaire and suggestion were
give to improve their appraisal procedure.

Keywords: Technical, Appraisal, Communication &

Training
Introduction and Review understood and measured. Too often, these standards are
articulated in ambiguous in ambiguous phases that tell
Once the employee has been selected, trained and
us little, such as “a full day’s work” (or) “a good job”.
motivated, he is then appraised for his performance.
What is a “full day’s work” or a “good job”? The
Performance appraisal is the step where to find out how
expectations a supervisor has in terms of work
effective if has been at hiring and placing employees.
performance by the employees must be clear enough
If any problems are identified steps are taken to
in her mind so that she will be able to, at some later
communicate with the employee and to namely them.
date, communicate these Expectations to her
A “Performance Appraisal is a process of evaluating
employees, mutually Agree to specific job performance
an employee’s performance of a job in terms of its
measures and appraisal their performance against these
requirements. It is the process of evaluating the
established standards.
performance and qualifications of the employees in
terms of the requirements of the job for which he is Improving Performance Management Practices
employed, for purposes of administration including in IT Firms of Pakistan. Results indicated that by
placement, selection for promotions, providing implementing steps of performance management
financial rewards and other actions which require processes i.e. setting objectives, training, performance
differential treatment among the members of group as agreement, and performance review and reward1.
distinguished from actions affecting all members Appraising Performance Appraisal Systems in the
equally viz., recruitment, selection, placement and Federal Government: A Literature Review, The result
indoctrination. The appraisal process begins with the suggests analyzing performance appraisal system
establishment of performance standards in accordance structures, beyond employee survey data; it provides to
with the organization’s strategic goals. These should the scholars with rich research opportunities 2. A
have evolved out of the company’s strategic direction – Study of Effect of Performance Appraisal on the
and, more specifically the job analysis and the job Organization and the Employee. The findings of the
description. The performance standards should also be research showed that there is a noticeable effect of the
clear and objective enough to be performance appraisal on the organization as well as on
the Individual 3. Performance Management System in
Corresponding Author: UK Retail Industry: it is a case Study. Findings showed
Dr. S. Poongavanam that, the organization is very powerful in employee
Associate Professor, performance management, as they are concerned for
AMET Business School, AMET University, Chennai both poor and high performer with corrective action and
Email: [email protected] reward respectively 4. Efficacy of Performance
Management System: An Empirical Study
282 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

at ICICI Bank. This research has attempted to minimize Statistical Tools Used:
the research gap existing in the field of efficacy of Percentage and Corelation
performance management system 5. An evaluation of the
Limitations of the Study
effectiveness of performance management systems on
service delivery in the Zimbabwean civil service”. It was z The study is concerned only with in the Pharmacy
concluded that the current performance management companies, Chennai.
system was not enhancing the provision of quality 6.
z The sample size is confined to 100 respondents.
Compensation is given to award the employees for their
efforts put in the company and to give guarantee that z The result of the study cannot be generalized for the
employees will stay in the same company and are entire organization as it is restricted few employees.
satisfied over a longer period. It is important, as it is a z Some of the employees were reluctant to fill up the
systematic way to plan the compensation for the questionnaire, as they are feared to give negative
employees7. The significance of the seniors-subordinate aspects against management
rapport and the role of communication system in
business are widely discussed in various studies. It
Analysis and Findings
highlights the workplace temperature, wetness and
airflow in the company and the way it kindle a good Table 1: Department
relationship between workers, senior and subordinate . 8
Department No. of respondents Percentage
Technical 44 44%
Objectives of the Study
Non-Technical 56 56%
z To study whether performance appraisal system Total 100 100%
is
communicated to the employees. Inference: From above table it inferred that 56% of the
respondents fall under the department of Non-technical,
z To study the awareness of health care system in the
44% of the respondents fall under the department of
Pharmacy companies.
technical.
z To study the socio-demographic factors of the
Table 2: Designation
employees in the Pharmacy companies
Designation No. of respondents Percentage
z To give viable suggestions.
Workmen 64 64%
Supervisor 28 28%
Research Methodology
Executive 8 8%
Research methodology is a way to solve the Total 100 100%
research problem systematically it may be understood
as a science of studying how search is done scientifically Inference: From the above table it inferred that 64%
study. We study the various steps that all generally 0f the respondents for under designation of
workmen,
adopted by a researcher in studying problem along with
28% 0f the respondents fall under the designation
the logic behind them. A study, which wants to portray
of supervisor, 8% of the respondents fall under the
the characteristics of a group or individual situation, is
designation of executive.
known as descriptive study. The main characteristic
of this method are that researcher has no control over Table 3: Age Group of Respondents
the variables. He can only report what has happened
Age No. of respondents Percentage
and what is happening. The researcher approached
20-30 0 0%
the employees individually questions were asked and
30-35 0 0%
information was collected. Question were explained so
35-40 36 36%
as to around ambiguity. The employees were found co-
operative. The data used for this study were both Above 64 64%
primary and secondary data. Sample size for this study is Total 100 100%
100.
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 283
Inference: From the above table it inferred that 64% of Inference: From the above table it inferred that 62% of
the respondents fall under the age group of above 40, the respondents are fully aware of health care system
36% of the respondents fall under the age group of 35-40. in the organization, 30% 0f the respondents are partly
aware to the statement, 8% of the respondents are little
Table 4: Experience Level of Respondents aware to above said statement.

Experience No. of
Percentage Table 8: Performance Appraisal Procedure is
Level respondents
Less than 10 0 0% Communicated in Advanced to You
11-20 26 26% Description No. of respondents Percentage
21-30 74 74% Always 0 0%
Above 30 0 0% Often 6 6%
Total 100 100% Sometimes 68 68%
Inference: From the above table it inferred that 74%
Not at all 26 26%
of the respondents have more than 21-30 years of
Total 100 100%
experience, 26% of the respondents have 11-20 years of
experience. Inference: From the table it inferred that 68% 0f the
respondents felt that performance appraisal procedure is
Table 5: Educational Level of Respondents communicated in advance sometimes only, 26% 0f the
respondents says not at all, 6% of the respondents feel
Educational level No. of respondents Percentage
often to the above statement.
Less than 10 th 0 0%
+2 18 18%
Diploma &ITI 30 30% Suggestions
Graduate & above 52 52% z The organization may take steps to communicate
Total 100 100% performance appraisal procedure in advance to
employees.
Inference: From the above table it inferred that 52%
of the respondents are graduated & above, 30% of the z Mechanisms to identify the employees’ potential
respondents are diploma or ITI, 18% 0f the respondents and to reward based on the potential and
performance rather than experience alone.
have +2 as their holders qualification.
z Motivate subordinates through recognition and
Table 6: Gender support. Performance appraisal system may help
the employee to achieve individual goals and
Gender No. of respondents Percentage organization’s goals.
Male 90 90%
Female 10 10%
Total 100 100% Conclusion
The study on employee performance appraisal helps
Inference: From the above table it inferred that majority
to identify the impact on changing business
of the respondents are male i.e. 90% and 10% 0f the
environment. The primary data was obtained through
respondents are female. questionnaire. The data are collected from 100
respondents and analyzed using statistical tools like
Table 7: Aware of the Employee Health Care System percentage analysis and correlation. Various suggestions
in Your Organization had been provided to the organization to improve health
care and employees’ performance appraisal.
Description No. of respondents Percentage
Fully aware 62 62% Ethical Clearance: Taken from AMET University,
Partially aware 30 30% Chennai.
Little aware 8 8%
Source of Funding: Self
Not at all 0 0%
Total 100 100% Conflict of Interest: Nil
284 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

REFERENCES 5. Devina Upadhyay, Anu Gupta. Morale, Welfare

1. Hassan Danial Aslam, Shakeel Sarwar. Improving measures, Job Satisfaction: The Key Mantras for
Performance Management Practices in IT firms of Gaining Competitive Edge. International Journal
Pakistan. Journal of management research2010: of Physical and Social Sciences, 2012; 91.
2(2). 6. Zvavahera, P. The Effect of Leadership on Service
Delivery in Universities. Research in Higher
2. Ellen V, Rubin. The performance of performance
Education Journal. 2013.
appraisal systems: understanding the linkage
between appraisal structure and appraisal 7. Srinivasan, Divyaranjini R. Impact of salary
discrimination complaints, The International and reward on the achievement in the pharma
journal of human resource management. 2011. companies. Indian Journal of Public Health
Research and Development. 2010;9(10): 1139-41
3. Singh Sanjeet. A Study of Effect of Performance
Appraisal on the Organization and the Employee. 8. Srinivasan, Divyaranjini R. Relationship study in
SSRN Electronic journals. 2011. work spot and communication system followed
in pharma companies. Indian Journal of Public
4. Miah Khasro M. Performance Management
Health Research and Development. 2010;9(10):
System In UK Retail Industry: A Case Study. Far
1142-44.
East Journal of Psychology and Business. Far
East Research Centre. 2012;7(2): 13-5.
DOI Number: 10.5958/0976-5506.2019.01579.1

A Study on Impact of Occupational Health and the Changing

Business Scenario of Corporate Appraisal

S. Poongavanam1, S. Jivita2
1
Associate Professor, 2Research Scholar, AMET Business School, AMET University,
Chennai

ABSTRACT
Performance appraisal has been defined as any personal decision that affects the status of employee
regarding their retention, termination, promotion, transfer, salary increase or decrease or admission into a
training Programme. This study focuses on corporate training give by the company and how it has its
impact on the changing business scenario. Data are collected through questionnaire and suggestion were
give to improve their appraisal procedure.

Keywords: Appraisal, Satisfaction, Training &

Measures
Introduction concluded that the current performance management
system was not enhancing the provision of quality 6.
Improving Performance Management Practices
Compensation is given to award the employees for their
in IT Firms of Pakistan. Results indicated that by
efforts put in the company and to give guarantee that
implementing steps of performance management
employees will stay in the same company and are
processes i.e. setting objectives, training, performance
satisfied over a longer period. It is important, as it is a
agreement, and performance review and reward 1.
systematic way to plan the compensation for the
Appraising Performance Appraisal Systems in the
employees7. The significance of the seniors-subordinate
Federal Government: A Literature Review, The result
rapport and the role of communication system in
suggests analyzing performance appraisal system
business are widely discussed in various studies. It
structures, beyond employee survey data; it provides to
highlights the workplace temperature, wetness and
the scholars with rich research opportunities 2. A
airflow in the company and the way it kindle a good
Study of Effect of Performance Appraisal on the
relationship between workers, senior and subordinate8.
Organization and the Employee. The findings of the
research showed that there is a noticeable effect of the The appraisal process:
performance appraisal on the organization as well as on
the Individual 3. Performance Management System in
UK Retail Industry: it is a case Study. Findings showed
that, the organization is very powerful in employee
performance management, as they are concerned for
both poor and high performer with corrective action and
reward respectively 4. Efficacy of Performance
Management System: An Empirical Study at ICICI
Bank. This research has attempted to minimize the
research gap existing in the field of efficacy of
performance management system 5. An evaluation of the
effectiveness of performance management systems on
service delivery in the Zimbabwean civil service”. It was

Corresponding Author:
Dr. S. Poongavanam,
Associate. Professor,
AMET Business School, AMET University, Chennai
Email: [email protected]
286 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Methods of Performance Appraisal Limitations of the Study

Traditional Methods: z The sample size is confined to 100 respondents.

z The result of the study cannot be generalized for the
1. Ranking method entire organization as it is restricted few employees.
2. Comparison method z Some of the employees were reluctant to fill up the
questionnaire, as they are feared to give
3. Grading negative
aspects against management
4. Graphic rating scales
5. Forced choice description method Analysis and Findings
6. Forced distribution method Table 1: Undergone Occupational Health Issues
7. Check lists Options No. of respondents
8. Free from essay method Yearly 34
Half Yearly 10
9. Critical incidents
Quarterly 56
10. Group appraisal Any other 0
11. Field Preview method Total 100
Objectives of the Study Inference: From the above table it inferred that 56% 0f
z To study the regularity of occupational health the respondents have undergone health issues quarterly,
issues 34% of the respondents have undergone yearly, 10% of
followed. the respondents have undergone half yearly.

z To identify the needs of performance appraisal Table 2: Satisfaction Level of Performance Rating
as Scale on Industry Standard
per the changes conducted in the organization.
Description No. of respondents Percentage
z To study the satisfaction level of present method of Highly Satisfied 0 0%
performance appraisal. Satisfied 34 34%
Dissatisfied 48 48%
Research Methodology Highly Dissatisfied 18 18%
Research methodology is a way to solve the Total 100 100%
research problem systematically it may be understood
Inference: From the table it inferred that 48% 0f the
as a science of studying how search is done scientifically respondents are dissatisfied with the performance rating
study. We study the various steps that all generally scale, 34% of respondents are satisfied to the above
adopted by a researcher in studying problem along with statement, 18% of the respondents are highly dissatisfied
the logic behind them. A study which wants to portray to the above statement.
the characteristics of a group or individual situation is
known as descriptive study. The main characteristic Table 3: Identifies Development Needs as Per the
of this method are that researcher has no control over Changes in Health Issues
the variables. He can only report what has happened
and what is happening. The researcher approached Description No. of respondents Percentage
the employees individually questions were asked and Fully identifies 8 8%
information was collected. Question were explained so Partly identifies 50 50%
as to around ambiguity. The employees were found co- Little identifies 28 28%
operative. The data used for this study were both Does not identifies 14 14%
primary and secondary data. Sample size for this study is Total 100 100%
100.

Statistical Tools Used: Percentage and Corelation

Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 287
Inference: From the above table it inferred that 50% 0f Suggestions
the respondents felt that, the health issues to partly
identify their developmental needs, 28% of the z The organization may take steps to create awareness
respondents felt it to be little identified, 14% of the among the employee among the health issues.
respondents feel it does not identify, 8% of the z Mechanisms to identify the employee’s potential
respondents feel it help them to fully identified their and to reward based on the potential and
development needs. performance rather than experience alone.
Table 4: The Most Appropriate Person to z Motivate subordinates through recognition and
Appraise support. Performance appraisal system may help
Description No. of respondents Percentage the employee to achieve individual goals and
Supervisors 30 30% organization’s goals.
Self 40 40%
Subordinates 16 16% Conclusion
All of the above 14 14% The study on employee performance appraisal helps
Total 100 100% to identify the impact on changing business environment.
The primary data was obtained through questionnaire. The
Inference: From the table it is found out that 40% of
data were collected from 100 respondents and analyzed
the respondents feel that the most appropriate persons to
using statistical tools like percentage analysis and
appraise is self, 30% of the respondents feel supervises
correlation. Various suggestions had been provided to the
are opt to the statement, 16% of the respondents feel
subordinates to the above statement and about 14% of organization to improve employees’ performance
the respondents feel that all of the above statement. appraisal.

Table 5: Satisfaction Level with the Present Ethical Clearance: Taken from AMET University,
Performance Appraisal Chennai.

Description No. of respondents Percentage Source of Funding: Self

Highly Satisfied 10 10% Conflict of Interest: Nil
Satisfied 56 56%
Dissatisfied 22 22% REFERENCES
Highly dissatisfied 12 12%
1. Hassan Danial Aslam, Shakeel Sarwar. Improving
Total 100 100%
Performance Management Practices in IT firms of
Inference: From the above table it inferred that 56% Pakistan. Journal of management research. 2010;
of the respondents are satisfied with the present method 2(2).
of performance appraisal, 22% of the respondents are
2. Ellen V, Rubin. The performance of performance
dissatisfied to the statement, 12% of the respondents
appraisal systems: understanding the linkage
are highly dissatisfied to the statement, 10% of the
respondents are highly satisfied to the above statement. between appraisal structure and appraisal
discrimination complaints. The International
Table 6: The Performance Rating is Based on the journal of human resource management. 2011.
Overall Health Behaviour
3. Singh Sanjeet. A Study of Effect of Performance
Description No. of respondents Percentage Appraisal on the Organization and the Employee.
Yes 67 67% SSRN Electronic journals. 2011.
No 33 33% 4. Miah Khasro M. Performance Management
Total 100 100% System in UK Retail Industry: A Case Study. Far
East Journal of Psychology and Business. Far
Inference: 67% of the respondents was accepted about
East Research Centre. 2012;7(2): 13-5.
the performance rating based on the overall health issues
and its behaviour 33% of them were not accepted with 5. Devina Upadhyay, Anu Gupta. Morale,
the statement Welfare
measures, Job Satisfaction: The Key Mantras for
288 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Gaining Competitive Edge. International companies. Indian Journal of Public Health

Journal Research and Development. 2010; 9(10): 1139-41
of Physical and Social Sciences. 2012; 91.
8. Srinivasan, Divyaranjini R. Relationship study in
6. Zvavahera P. The Effect of Leadership on Service work spot and communication system followed
Delivery in Universities. Research in Higher in pharma companies. Indian Journal of Public
Education Journal. 2018. Health Research and Development. 2010;
7. Srinivasan, Divyaranjini R. Impact of salary 9(10):
and reward on the achievement in the pharma 1142-44.
DOI Number: 10.5958/0976-5506.2019.01580.8

An Empirical Study on Employee Health and FIRO-B

Relationship

S. Poongavanam1, K. Viswanathan2
1
Associate Professor, 2Research Scholar, AMET Business School, AMET University,
Chennai

ABSTRACT
The Fundamental Interpersonal Relations Orientation–Behavior (FIRO-B) instrument was created in the late
1950s by William Schutz. He developed the FIRO-B theory to aid in the understanding and predicting of
how high-performance military teams would work together. This article focus on deterioration of
employee’s health due to the poor relationship among employees. Convenience sampling techniques is used
to collect data for the analysis. The study shows the importance of FIRO B relationship among the
employees.

Keywords: Interpersonal relationship, Policies, Conference and

Gaps.
Introduction Apart from being a helpful coaching and
development tool to build deeper self-awareness,
FIRO-B “Fundamental Interpersonal Relations
FIRO-B “Fundamental Interpersonal Relations
Orientation-Behaviour” was developed by Dr Willis
Orientation-Behaviour” can also provide helpful insight
Schultz for the US Government during the Korean War
into an individual’s possible compatibility with others
to assess individual’s inter-personal needs and how these
in different situations. It is therefore widely used in
may affect their behaviour towards others. This
any situation requiring a measurement of interpersonal
instrument has been ethically researched and validated in
behaviour and the likely needs of others, including
many countries and is widely used not just in team
management development, team building and employee
building in the work-place and management
development.
development, but also in individual and family
relationship –counselling. FIRO-B “Fundamental There has been little research on whether providing
Interpersonal Relations Orientation-Behaviour” a range of family-friendly policies raises workplace
measures how much people may need others, performance, there is some evidence to link individual
particularly in terms of: Inclusion and how much practices with enhanced productivity. It was found
contact, attention and recognition you may generally that employees had greater enthusiasm for their work
want to give others in your life and receive back; where they were employed on a part-time basis, which
z Control, and how much influence, responsibility might then be expected to generate higher productivity
and structure you may seek in your relationships,
(3).
Certainly, some part-time workers believe that they
whether to lead and direct others or to be led; are more productive than when they were previously
working fulltime (1). The fact that part-time employees
z Affection, or openness, and how close and may not require a paid break can also reduce costs for
warm the employer (5). The researchers cite evidence that part-
you are with others and want others to be with you. time workers experience lower levels of stress than
full-time employees do, and have lower absenteeism
rates (2). Employers of part-time workers are also able
to call on the skills of a larger number of employees,
Corresponding Author: and retain experienced staff who wish to reduce their
Dr. S. Poongavanam hours and might otherwise seek alternative employment
Associate. Professor, (2).
Given that the average cost of labour turnover has
AMET Business School, AMET University, Chennai been estimated at £3,546 per employee, the savings
Email: [email protected]
290 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

made by retaining employees could be significant (4). already been passed through statistical process
Compensation is given to award the employees for their secondary data be published or unpublished data.
efforts put in the company and to give guarantee that
employees will stay in the same company and are
satisfied over a longer period. It is important, as it is a
systematic way to plan the compensation for the
employees6. The significance of the seniors-subordinate
rapport and the role of communication system in
business are widely discussed in various studies. It
highlights the workplace temperature, wetness and
airflow in the company and the way it kindle a good
relationship between workers, senior and subordinate7.

Objectives of the Study

z To study employees health issues and its impact
onf
communications system.
z To study satisfaction level of
interpersonal
relationship and policies exist in the organization.
z To study the opinion of training session on
health
issues conducted in the company.

Limitations of the Study

z Time and cost factors.
z Study cannot be
generalized.
z Employees are not ready to give the correct answer
fearing of action from the management,

Research Methodology

Research design is the arrangement of conditions for

collection and analysis of data a systematic manner that
aims to combine relevance to the research purposes with
economic in procedure. Descriptive research design is
used to study Interpersonal Relationship of work place
in Tirupattur Co-Operative Sugar Mills Ltd. This study
includes both primary data and secondary data.
z Primary data
z Secondary data

Primary data are those which are collected a fresh

and for the first time and thus happen to be original in
character. For this project study questionnaire method
is used. The secondary data are those data which have
already been collected by some else and which have
291 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
“A sample design is a definite plan for obtaining
a sample form a given population”. It refers to the
technique (or) procedure that researcher would adopt
in selecting item for sample, design may be as well lay
down the numbers of items included in the sample i.e.
the size of the sample.

The size of the represents sample is for 75 out of

the total population 338. In this study the researcher
has used convenient sampling techniques to select the
sample size.

Data Analysis and Interpretation

Table 1: Opinion about respondents on satisfaction

level on Employee health is accepted or consider by
management
S. No. of Percentage
Particulars
No. Respondents (%)
1. Highly Satisfied 10 14
2. Satisfied 38 49
3. Neutral 15 20
4. Highly Dissatisfied 8 11
5. Dissatisfied 4 6
Total 75 100

The above table shows that 14% of the respondents

are highly satisfied, 49% of the respondents are
satisfied, 20% of the respondents are neutral, 11% of the
respondents are highly dissatisfied, 6% of the
respondents are dissatisfied on satisfaction level on
employee health is accepted or consider by the
management.

Majority of the respondents are 49%

Table 2: Opinion about Respondents on Important

Tool Need to Use by the Employees on Faro-B
“Fundamental Interpersonal Relations Orientation-
Behaviour” Aspect
S. No. of Percentage
Particulars
No. Respondents (%)
1. Inclusion 14 19
2. Control 34 44
3. Affection 27 37
Total 75 100

From the above table, it is noted that 19% of

the
respondents need inclusion and 44% of the respondents
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 291
need control and 37% of the respondents need affection Table 5: Opinion about the respondents on the
as an important tool need to employees on firo-b aspect. general complaints about failure of the interpersonal
Majority of the respondents are 44%. relationship between employees in an organization
S. No. of Percentage
Table 3: Opinion about Respondents of training on Particulars
No. Respondents (%)
Interpersonal Relationship in an Organization Take Away
Precious Time
S. No. of Percentage 1. 40 55
Particulars of Employees by
No. Respondents (%) Giving Training
On the Job Too Many Gaps
1. 16 21
Training 2. between the 35 45
2. External Training 24 30 Departments
3. Conference 16 22 Total 75 100
4. Discussion 14 20 From the above table, it is noted that 55% of the
Programmed respondents are make the complaints by taking away
5. 5 7 precious time of employees by giving training and 45%
Instruction
of the respondents are make on the complaints by too
Total 75 100
many gaps between the departments in an organization
The above table shows that 21% of the respondents
on the inter personal relationship between employees.
are favour of on the job training, 30% of the respondents
are favour of the external training, 22% of the Majority of the respondents are 55%
respondents are favour of the conference, 20% of the
z 39% of the respondents were preferred 1-5 years
respondents are favour of the discussion, 7% of the
for making betterment on inter-personal
respondents are favour of on the programmed instruction relationship with employees in an organisation.
on health issues on training and development to
employees on interpersonal relationship in an
Conclusion
organization.
Majority of the respondents are 30% The FIRO-B “Fundamental Interpersonal Relations
Orientation-Behaviour” test was conducted to be find
Table 4: Opinion about Respondents Opinion out three main interpersonal aspects of human behaviour
Regarding the health issues i.e., inclusion, control and affection with 75 respondents.
The study is conducted among the employees of various
S. No. of Percentage departments. It is concluded that there is a need to
Particulars
No. Respondents (%)
improve the interpersonal relationship between the
1. Excellent 12 16 employees in order to maintain a cordial relationship.
2. Very Good 33 43
3. Good 20 27 Ethical Clearance: Taken from AMET University,
4. Average 3 5 Chennai.
5. Poor 7 9 Source of Funding: Self
Total 75 100
Conflict of Interest: Nil
The above table shows that 16% of the respondents
are excellent, 43% of the respondents are good, 27% of REFERENCES
the respondents are average, 5% of the respondents are
below average, 9% of the respondents on training 1. Lewis S. Family Friendly Employment and
session conducting in the organization at present to Policies: a Route to Changing Organizational
Culture or Playing About at the Margins?.
increase the employee health.
Gender, Work and Organization. 1997;4(1):. 13-3.
Majority of the respondents are 43%
292 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

2. Duffy A, Pupo N. (1992), The Part-Time 5. Industrial Relations Services. Part-Time Workers:
Experience: the Work Connection in Part Time. In from the Periphery. IRS Employment
Paradox: Connecting Gender, Work, and Family. Trends.
McClelland and Stewart Inc. Toronto.1992. 2001;725: 4-10.

3. Skinner D. The Reality of Equal Opportunities: 6. Srinivasan, Divyaranjini R. Impact of salary

The Expectations and Experiences of Part-Time and reward on the achievement in the pharma
companies. Indian Journal of Public Health
Staff and their Managers. Personnel
Research and Development. 2010; 9(10): 1139-41
Review.
1999;28(5): 425-38. 7. Srinivasan, Divyaranjini R. Relationship study in
work spot and communication system followed
4. Institute of Personnel and Development. Staff in pharma companies. Indian Journal of Public
Turnover Costs Rise by 10.5 per cent. People Health Research and Development. 2010;
Management. 2000: 8. 9(10):
1142-44.
DOI Number: 10.5958/0976-5506.2019.01581.X

An Empirical Study on Environmental Hazards and

Recruitment Process in Health Care Compnies, Chennai

S. Poongavanam1, K. Viswanathan2
1
Associate Professor, 2Research Scholar, AMET Business School, AMET University,
Chennai

ABSTRACT
Importance of environmental hazard in health care companies are raising year by year, due to the problems
faced by the employees in the work sport. Recruitment refers to the process of finding possible candidates
for a job or function, usually undertaken by recruiters. It also may be undertaken by an employment agency
or a member of staff at the business or organization looking for recruits. Advertising is commonly part of
the recruiting process, and can occur through several means: through online, newspapers, using newspaper
dedicated to job advertisement, through professional publication, using advertisements placed in windows,
through a job center, through campus graduate recruitment programs.

Keywords: Health care, Recruitment, Expectation & Commitments

Introduction activities in the organizations must considered while
designing the growth2. Among recruitment sources
Environmental hazards is increasing year by year in
internal source of recruitment is effective compared to
few companies, since the management is not considering
the external source2. Few researchers say that compared
it an important factors which affects the wellbeing of the
to the traditional recruiting sources the modern sources
employees. Suitability for a job is typically assessed by
like referrals, casual applicants and direct approaches
looking for skills, e.g. Communication skills, typing
will benefit at large3. Selection procedure also should be
skills, computer skills. Evidence for skills required for a in application to the modern techniques4. The literature
job may be provided in the form of qualifications says that employers are doing the traditional method
(educational or professional), experience in a job of recruiting rather than the modern technologies. It
requiring the relevant skills or the testimony of is noted in an article that around all the organizations
references. Employment agencies may also give are using traditional recruitment sources and 30%
computerized tests to assess an individual’s “off-hand” of organizations are screening candidate’s honestly5.
knowledge of software packages or typing skills. At a According to SHRM (Society for Human Resource
more basic level written tests may be given to assess Management) that 15% joined in the organizations are
numeric and literacy. A candidate may also be assessed placing false resume7. Some of the employers select
on the basis of an interview. Sometimes candidates will the candidates with discrimination even though it is not
be requested to provide a résumé (also known as a CV) supposed to be done in the organizations6. Compensation
or to complete an application form to provide this is given to award the employees for their efforts put
evidence. in the company and to give guarantee that employees
will stay in the same company and are satisfied over
Recruitment and selection practices of the small and
a longer period. It is important, as it is a systematic
medium enterprises and make them to improve their HR
way to plan the compensation for the employees8. The
practices1. The importance of selection and recruitment
significance of the seniors-subordinate rapport and the
role of communication system in business are widely
Corresponding Author: discussed in various studies. It highlights the workplace
Dr. S. Poongavanam temperature, wetness and air flow in the company and
Associate Professor, the way it kindle a good relationship between workers,
AMET Business School, AMET University, Chennai senior and subordinate9.
Email: [email protected]
294 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 294

Objectives The above table shows that 91% of the employees

To study the recruitment practices followed in were happy with the recruitment process followed in
Health Care Company. Health care limited.

To study the environmental hazards and expectation Table 2: Did the company meet your expectations on
levels of employees in Health Care company. environmental hazards?
To study the opening and employees referrals in the
Expectation No. of Respondents Percentage
organization.
Yes 70 93.3
To give viable suggestions. No -- --
Research Methodology Can’t Tell 5 6.7
Total 75 100
Field of study: The research work was carried out at
Health Care companies Chennai. It is inferred from the above table that 70% of
the
Research samples: Sample is chosen from the Health respondent feels that the company meet their
care companies as it portrays the needs of the researchers. expectation.
Research provides an insight into any study top basically
evaluate and judge the data or to find the solution to any Table 3: Are you happy with the salary offered
given problem a simple is representative of a group or from the company?
population that identifies itself as part of it. The sample
chosen for this study is from Health Care Company Salary offered No. of Respondents Percentage
Chennai. Yes 24 32
No 51 68
Data Collection Total 75 100

The data collected contains primary data and It is clearly inferred that 68% of employees
secondary data. The primary data has been collected feels
mainly by interviewing and also observation and audit. they are happy with the salary offered in the company.
Secondary data has been obtained from published
journals, company broachers, books, internet, etc. Table 4: Did the company fulfill the commitments
given at the time of interview on health issues?
Limitations:
Commitments No. of Respondents Percentage
z The study was completed within short span of time
that was available. Yes 42 56
No 13 17.3
z The report also suffers from the limitations
of exhaustiveness as far as the information is Can’t Tell 20 26.7
concerned. Total 75 100

z Health Care Company in Chennai only is The above table shows that 56% of employees feels
considered that the company fulfills the commitment given at the
for this study. time of interview, 27% employees selected the option
that they can’t tell, 18% feels Company does not fulfills
Results and Discussion the commitments on health issues.

Table 1: Are you happy with the Recruitment Table 5: How do you come to know about openings?
Process?
Opening No. of Respondents Percentage
Recruitment No. of
Friends 5 Percentage 6.7
Process Respondents
Internet 23 30.7
Yes 68 90.7
News Papers 40 53.3
No 7 9.3
Others 7 9.3
Total 75 100
Total 75 100
The above table shows that 53% of employees Conclusion
came to know about the opening through newspaper
advertisement given by the company, 31% feels internet Environment hazards, Recruitment and selection
is the major source to know the opening, 7 through plays a important role in the company. The study reveals
friends. % came to know through friends. that the environment practice, recruitment process
offered in the organization is very effective. The HR
Table 6: Do you want to refer more friends on manager of the health care company focus on selecting
satisfaction of health issues? the right persons through many sources viz., campus
placements, internet, private agency, Government
Refer friends No. of Respondents Percentage employment etc. The selection is done by evaluating the
Yes 58 77.3 candidate skills, knowledge and abilities which are
No 8 10.7 highly required to the vacancies in selected industries.
Not Replied 9 12 Ethical Clearance: Taken from AMET University,
Total 75 100 Chennai.

77% of employees selected the options that they Source of Funding: Self
refer to their friends about the opening and 11% feels
Conflict of Interest: Nil
that they won’t refer to their friends.

REFERENCES
Chi-Square Test–Health Care Versus Employee
Well Being 1. Omolo RD. Effect of Recruitment and Selection
of employees on the performance of small and
Null Hypothesis (Ho): There is no significant medium enterprises in Kisumu municipality,
relationship between health care and employee Kenya. International Journal of Human Resource
wellbeing in the company. Studies. 2012; 81-98.
2. John HB. Human Resource Management: An
Level of Significance = 5%
Experimental approach. New Delhi: McGraw-
Degree of freedom – 9 Hill, 2003.
3. Barclay LP. Recruiting Sources: Another Look.
Calculated value = 34.91 Journal of Applied Psychology. 1985; 20-8.
Tabulated value =16.92 4. Smith MI. Personal Selection. Journal of
occupational and organizational psychology.
Since Calculated value is greater than Tabulated 2001; 441-72.
value. 5. Armstrong CP. Current Recruitment and Selection
Practices: A National Survey of Fortune 1000
Result Firms. North American Journal of Psychology.
2006; 489-96.
From the above analyses it is inference that the 6. Fomunjong MG. Recruitment and Selection.
calculated the value is 34.91 greater the tabulated value University of Gothenburg. 2009.
is 16.92. Hence, null hypothesis is rejected. 7. Gusdorf ML. Recruitment and Selection: Hiring
the Right Person. USA. Society for Human
Suggestions Resource Management. 2008.
8. Srinivasan, Divyaranjini R. Impact of salary
z Create awareness among employees on the
and reward on the achievement in the pharma
importance of environmental hazards.
companies. Indian Journal of Public Health
z Increase the competence levels among the Research and Development. 2010; 9(10): 1139-41
employees by giving suitable Training on the use of 9. Srinivasan, Divyaranjini R. Relationship study in
equipment which causes accidents. work spot and communication system followed
z Provide training to the employee in Health Care in pharma companies. Indian Journal of Public
Health Research and Development.2010; 9(10):
company enhances the knowledge, skills and
attitude. 1142-44.
DOI Number: 10.5958/0976-5506.2019.01582.1

Impact of Health Care Laws and Employee Relationship,

Policies in Pharma Companies–A Study

S. Poongavanam
Associate. Professor, AMET Business School, AMET University,
Chennai

ABSTRACT
Understanding of Health care laws, friendly responsive policies, employee loyalty, social exchange, role,
and social justice plays vital role for the satisfaction theory. Gender, age, qualification differences the likely
impact of the differences on satisfaction of policies and friendly relationship is discussed. Finally, it also
address the likely connections among friendly policies and company policy

Keywords: Relationship, policies, health care and friendly

policy.
Introduction working fulltime (1). The fact that part-time employees
may not require a paid break can also reduce costs for
Health care plays a major role for the employees the employer (5). The researchers cite evidence that part-
working in the factory where more hazardous elements time workers experience lower levels of stress than
occurs on day to day basis. Fundamental Interpersonal full-time employees do, and have lower absenteeism
Relations Orientation-Behaviour is to access the rates (2). Employers of part-time workers are also able
employee’s inter-personal needs and how it will affect to call on the skills of a larger number of employees,
the behaviour of others. This instrument has been and retain experienced staff who wish to reduce their
ethically researched and validated in many countries and hours and might otherwise seek alternative employment
is widely used not just in team building in the work- (2).
Given that the average cost of labour turnover has
place and management development, but also in been estimated at £3,546 per employee, the savings
individual and family relationship. It is therefore made by retaining employees could be significant (4).
widely used in any situation requiring a measurement of Compensation is given to award the employees for their
interpersonal behaviour and the likely needs of others, efforts put in the company and to give guarantee that
including management development, team building and employees will stay in the same company and are
employee development. satisfied over a longer period. It is important, as it is a
systematic way to plan the compensation for the
There has been little research on whether providing employees6. The significance of the seniors-subordinate
a range of family-friendly policies raises workplace rapport and the role of communication system in
performance, there is some evidence to link individual business are widely discussed in various studies. It
practices with enhanced productivity. It was found highlights the workplace temperature, wetness and
that employees had greater enthusiasm for their work airflow in the company and the way it kindle a good
where they were employed on a part-time basis, which relationship between workers, senior and subordinate7.
might then be expected to generate higher productivity
(3).
Certainly, some part-time workers believe that they
Objectives of the Study
are more productive than when they were previously
z To study Health care laws, policy in Health
care
Corresponding Author: companies.
Dr. S. Poongavanam z To study satisfaction level of interpersonal
Associate. Professor, relationship and policies exist in the organization
AMET Business School, AMET University, Chennai and it helps to improve the health care.
Email: [email protected]
z To give a viable suggestion.
297 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 297

Limitations of the Study Conted…

z Time and cost factors.
4. Ug 25 33
z Study cannot be generalized. 5. Pg 0 0
z Employees are not ready to give the correct answer Total 75 100
fearing of action from the management,
The above table shows that 27% of the respondents
belong to the SSLC holders, 13 % of the respondents
Research Methodology
belong to the HSC holders, 27 % of the respondents
Research design is the arrangement of conditions for belong to the DIPLOMA holders, 33% of the
collection and analysis of data a systematic manner that respondents belong to the UG holders, and 0% of the
aims to combine relevance to the research purposes with respondents belong to the PG holders.
economic in procedure. Descriptive research design is
Majority of the respondents are UG holders 33%
used to study Interpersonal Relationship of work place
in Tirupattur Co-Operative Sugar Mills Ltd. This study
Table 2: Opinion about respondents on marital
includes both primary data and secondary data.
status of employees
z Primary data
S. No. of Percentage
z Secondary data Particulars
No. Respondents (%)
Primary data are those which are collected a fresh 1. Yes 73 97
and for the first time and thus happen to be original in 2. No 2 3
character. For this project study questionnaire method Total 75 100
is used. The secondary data are those data which have
already been collected by some else and which have From the above table, it is noted that 97% of the
already been passed through statistical process respondents are married and 3% of the respondents are
secondary data be published or unpublished data. unmarried.

“A sample design is a definite plan for obtaining Majority of the respondents are married 97%.
a sample form a given population”. It refers to
the technique (or) procedure that researcher would adopt Table 3: Opinion about Working Experience of the
in selecting item for sample, design may be as well lay respondents
down the numbers of items included in the sample i.e.
S. No. of Percentage
the size of the sample. Particulars
No. Respondents (%)
The size of the represents sample is for 75 out of 1. Below 1 Years 2 3
the total population 338. In this study the researcher 2. 1-5Years 4 5
has used convenient sampling techniques to select the 3. 5-10Years 9 12
sample size. 4. 10-15Years 11 15
5. Above 15 Years 49 65
Result and Discussion Total 75 100

The above table shows that 3% of the respondents

Table 1: Opinion about Educational qualification of
belong to the below 1 year of experience, 5% of the
the respondents
respondents belong to the 1-5 years of experience,
S. No. of Percentage 12% of the respondents belong to the 5-10 years of
Particulars
No. Respondents (%) experience, 15% of the respondents belong to the 10-15
1. Sslc 20 27 years of experience, 65% of the respondents belong to
2. Hsc 11 13 the above 15 years of experience.
3. Diploma 19 27
Majority of the respondents are experience 65%
Table 4: Opinions about respondents maintain The above table shows that 14% of the respondents
a friendly relationship with employees in an are highly satisfied, 49% of the respondents are
organization satisfied, 20% of the respondents are neutral, 11% of the
respondents are highly dissatisfied, 6% of the
S. No. of Percentage
Particulars respondents are dissatisfied on satisfaction level on
No. Respondents (%)
opinion on health issues is accepted or consider by the
1. Strongly Agree 19 24 management.
2. Agree 34 45
3. Neutral 19 26 Conclusion
4. Strongly Disagree 1 2
5. Disagree 2 3 The study concludes that implementation of health
care law is a must in all the factories. The fundamental
Total 75 100
Interpersonal Relations Orientation-Behaviour test was
The above table shows that 24% of the respondents conducted to be find out three main interpersonal aspects
of human behaviour i.e., inclusion, control and affection
are strongly agree, 45% of the respondents are
agree, with 75 respondents. The study is conducted among the
employees of various departments. It is concluded that
26% of the respondents are somewhat agree, 2% of the
there is a need to improve the interpersonal relationship
respondents are strongly disagree, 3% of the respondents
between the employees in order to maintain a cordial
are disagree on maintaining a friendly relationship with
relationship.
employees in an organization.
Ethical Clearance: Taken from AMET University,
Majority of the respondents are employees in an Chennai.
organization 45%
Source of Funding: Self
Table 5: Opinions about respondents on satisfaction Conflict of Interest: Nil
about the company policies on health care
REFERENCES
S. No. of Percentage
Particulars 1. Lewis S. Family Friendly Employment and
No. Respondents (%)
Policies: a Route to Changing Organizational
1. Yes 51 67 Culture or Playing About at the Margins?.
2. No 24 33 Gender, Work and Organization. 1997; 4(1): 13-
Total 75 100 23.
2. Duffy A, Pupo, N. The Part-Time Experience:
From the above table, it is noted that 67% of the
the Work Connection in Part Time. Paradox:
respondents are satisfied and 33% of the respondents are
Connecting Gender, Work, and Family. 1992.
not satisfied with the policies in the company regarding
health care. 3. Skinner D. The Reality of Equal Opportunities:
The Expectations and Experiences of Part-Time
Majority of the respondents are policies 67% Staff and their Managers. Personnel
Review.
Table 6: Opinion about respondents on satisfaction 1992;8(5): 425-38.
level on opinion on Health laws accepted or consider
4. Institute of Personnel and Development. Staff
by management Turnover Costs Rise by 10.5 per cent. People
S. No. of Percentage Management. 2000; 8.
Particulars
No. Respondents (%) 5. Industrial Relations Services. Part-Time Workers:
1. Highly Satisfied 10 14 In from the Periphery. IRS Employment
2. Satisfied 38 49 Trends.
2001; 725: 4-10.
3. Neutral 15 20
6. Srinivasan, Divyaranjini R. Impact of salary
4. Highly Dissatisfied 8 11
and reward on the achievement in the pharma
5. Dissatisfied 4 6 companies. Indian Journal of Public Health
Total 75 100 Research and Development. 2010; 9(10):1139-41
7. Srinivasan, Divyaranjini R. Relationship study in
work spot and communication system followed in
pharma companies. Indian Journal of Public
Health Research and Development.
2010;9(10):1142-44.
DOI Number: 10.5958/0976-5506.2019.01583.3

Antioxidants and Antibodies in Structural Thyroid Diseases

Anita P Javalgi1, B R Yelikar2, Kusal Das3

1
PhD Scholar, 2Prof & Head, 3Professor, Department of Pathology, BLDE University’s Shri B M
Patil
Medical College, Vijayapura, Karnataka

ABSTRACT
Thyroid nodules are a very frequent finding, and their prevalence steadily increases with age. Routinely
clinical factors such as age, gender, and radiation history are meaningful for predicting thyroid nodules.
There are few studies exploring the association of serum indexes of thyroid hormones or autoantibodies
with the risk of thyroid nodules. Hence present study was undertaken with following objectives. To
measure the serum markers of FT3, FT4,TSH, anti TPO antibody, anti-thyroglobulin antibody and role of
Vitamin E and vitamin C antioxidants in relation with thyroid serum markers in various thyroid diseases.
Correlation of these serum markers with cytological diagnosis was done. Serum analysis of thyroid
hormones, autoantibodies level and FNAC was done with patients having thyroid swelling.
It was noted in present study that prevalence of positive serum autoantibodies displays geographical
heterogeneity, unrelated to goitre prevalence. Autoantibodies levels are raised in autoimmune thyroid
diseases and in few variants of thyroid malignancy. And it was also observed anti-Oxidants (vitamin e
and vitamin c) levels were variable in thyroid disorders. To conclude autoantibodies are markedly raised
in thyroiditis condition and the incidence of autoimmune thyroiditis is increasing in iodine sufficient as
well as iodine deficient geographical areas. In present study it was also observed that autoantibodies levels
were raised in papillary carcinoma thyroid indicating role of anti-TPO and anti-TG in etiopathogenesis.
Antioxidants levels were variable and low in most of thyroid diseases suggesting its role in
etiopathogenesis.

Keywords: auto-antibodies, antioxidants, goitre, papillary

carcinoma
Introduction autoantibodies with the risk of thyroid nodules.
Although thyroid hormones and autoantibodies are
Thyroid diseases are among the commonest
reported to be dependently associated with thyroid
endocrine disorders worldwide. India too, is no
function and thyroid diseases, little attention has been
exception. According to a projection from various
paid to whether thyroid hormones and autoantibodies are
studies on thyroid disease, it has been estimated that
associated with thyroid nodules2. Thyroid nodule, as an
about 42 million people in India suffer from thyroid
entity, is one of the most common diseases originating
diseases. Routinely clinical factors such as age, gender,
from the endocrine system. Thyroid nodules may be
and radiation history are meaningful for predicting
single, multiple, solid, or cystic and may or may not be
thyroid nodules. There are few studies exploring the
functional.3 Most thyroid nodules are benign tumours
association of serum indexes of thyroid hormones or
and 5% are reported as malignant.4,5
Autoimmune thyroiditis (AT) is a common disorder of
the thyroid gland. It is usually diagnosed when thyroid
autoantibodies (TPOAbs/TGAbs) are detected in
Corresponding Author:
patients with hypothyroidism or goiter.6
Dr Anita P Javalgi
Department of Pathology Autoimmune diseases (AID) appear when the host
BLDE University’s Shri B M Patil Medical College immune system turns against its own antigens leading
Vijayapura, Karnataka to dysfunction or destruction of tissues and organs.
Phone: 09590196666 AID may develop in mechanisms involving immune
Email: [email protected] deregulation, genetic predisposition and due to influence
of environmental factors.7 Thyroid autoimmune
300 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 300

diseases like GD and Hashimoto thyroiditis (HT) affect of Pathology for FNAC. Patients with thyroid swelling
the thyroid gland and are called autoimmune thyroid with thyroid hormone therapy or antithyroid drugs were
diseases (AITD).8 excluded.

Oxidative reactions occur in all tissues and organs, Early morning fasting 5ml of venous blood sample
thyroid gland being one, in which oxidative processes was collected in plane vaccutainer and the collected
are indispensable for thyroid hormone synthesis. Both serum sample was run through Vidas biochemical
hyper- and hypothyroidism have been proven to promote analyzer based on the principal chemiluminescent
cellular oxidative stress by influencing the intensity immunoassay. Serum markers estimation included Free
of oxygen reactions and have been shown to affect thyroxine(T4), Free tri-iodothyronine (T3), Thyroid
concentrations of the vitamins involved in scavenging stimulating hormone (TSH), Anti thyroglobulin antibody
of free radicals (usually decreasing their concentrations, (AntiTG ab), Anti thyroperoxidase (anti TPO), Vitamin
although study results differ) i.e. vitamins A, C and E.9 C and E levels (HPLC method).

Therefore, this study was undertaken to determine Descriptive statistics as well as 95% confidence
whether there is an association between thyroid nodules, interval for a single proportion and a mean was
thyroid hormones levels and thyroid autoantibodies and calculated.
correlation of these markers with cytological diagnosis.
Also an attempt to understand the role of Vitamin E and Results
vitamin C antioxidants in relation in various thyroid
diseases was made. In this one year cross sectional study total 54cases
with thyroid swelling referred to cytology section were
Methodology included and all cases we had serum biomarker level
estimation. In present study females outnumbered males
This was prospective study carried out in 2016 with 43 females (79%) and 11 males (21%), youngest
at out tertiary care hospital. The study group includes being 12yrs and oldest age 72yrs.(TABLE I: AGE
patients with thyroid swelling referred to Department DISTRIBUTION)
Table I: Age distribution
Sex/age 10-20 21-30 31-40 41-50 51-60 61-70 >70 Total
Female 5 14 10 5 6 2 1 43
Male 1 2 3 3 1 1 - 11

The commonest thyroid disease was colloid goiter followed by thyroiditis. Lymphocytic thyroiditis was
common followed by granulomatous thyroiditis and other variants. Papillary carcinoma was commonest malignant
lesion affecting females in 3rd and 4th decade.(Table II)

Table II: Various thyroid diseases with sex distribution of disease

Thyroid lesion Females Males Total
Goitre (colloid/nodular/toxic) 13 3 16
Lymphocytic thyroiditis 14 1 15
Granulomatous thyroiditis 2 2 4
Graves disease 7 0 7
Follicular neoplasm
Follicular adenoma 1 2 3
Follicular carcinoma 0 2 2
Papillary carcinoma 6 0 6
Medullary carcinoma 0 1 1
Total 43 11 54
Thyroid function test (free T3, free T4 and TSH) and autoantibodies level ie anti-TPO and anti-TG levels were
measured and mean calculated with SD and observed that most of thyroid disorders were in euthyroid state and
autoantibodies level were raised in autoimmune thyroiditis and few cases of papillary carcinoma. (Table III).

Table III: Thyroid function test and auto-antibodies level in thyroid diseases
TSH FT3 FT4
Anti TG Anti TPO
Thyroid lesion Total 0.4-4.0 3.5-7.8 9 – 25
<20 IU/ml < 35 IU/ml
muIU/ml pmol/L pmol/L
Goitre (colloid/nodular/toxic) 16 1.62+/-0.76 3.02+/-042 1.22+/-0.24 16.63+/-3.42 35.2+/-3.23
Lymphocytic thyroiditis 15 20.66+/-4.05 1.42+/-0.37 .53+/-0.16 43.25+/-7.46 63.26+/-5.96
Granulomatous thyroiditis 4 2.22+/-0.43 6.24+/-1.56 19.45+/-6.5 26+/-3.50 35.2+/-2.50
Graves disease 7 0.02+/-0.01 13.3+/-3.69 30+/-4.79 34.85+/-6.76 42.28+/-5.92
Follicular neopalsm;
Follicular adenoma 3 0.83+/-0.16 4+/-1.73 11.3+/-1.67 12.6+/-3.77 25+/-0
Follicular carcinoma 2 2+/-0 3.9+/-0.1 20+/-0 12+/-1.41 17.5+/-2.42
Papillary carcinoma 6 2.1 +/- 0.54 4.65+/-1.16 13.8+/-4.16 30.5+/-14.53 33.3+/-17.93
Medullary carcinoma 1 0.9 4 13 20 39

Also anti-oxidants levels i.e. Vitamin C and Vitamin E were measured and observed that the levels were affected
in thyroid abnormality with markedly reduced level in malignancy followed by thyroiditis and then goiter. (Table
IV)

Table IV: vitamin C & vitamin E measurements in various thyroid diseases

Thyroid lesion Total Vitamin C level 0.2–2.0 mg/dl Vitamin E level 5–20 µg/ml
Goitre (colloid/nodular/toxic) 16 1+/-0.56 9+/-1.5
Lymphocytic thyroiditis 15 0.1+/-0.01 1.75+/-0.5
Granulomatous thyroiditis 4 0.45+/-0.5 4.5+/-1.2
Graves disease 7 0.5+/-0.06 1.62+/-0.04
Follicular neopalsm;
Follicular adenoma 3 0.2+/-0.01 4.6+/-1.3
Follicular carcinoma 2 0.2+/-0.01 3+/-1.2
Papillary carcinoma 6 0.7+/- 0.04 2.18+/-0.56
Medullary carcinoma 1 0.4 2
Discussion Most of autoimmune thyroid diseases are
accompanied by the presence of anti-thyroid peroxidase
Thyroid nodule is one of the most common diseases
(TPO), anti-thyroglobulin (Tg), and anti-thyroid-
originating from the endocrine system.. Thyroid
swelling may or may not be associated with functional stimulating hormone receptor (TSHR) antibodies.
derangement. The thyroid epithelial cells, induced by However autoantibodies association with thyroid
random mutations or rearrangements, will grow from malignancy is also noted in few papillary carcinoma
a normal state to an abnormal state. This induction of of thyroid. Antibodies against thyroid antigens such as
growth exacerbates cellular mutagenesis that generates carbonic anhydrase, megalin, T3 and T4, sodium iodide
the nodules. 10,11 Most thyroid nodules are benign symporter (NIS), and pendrin have also been detected,
tumours and 5% are reported as malignant.4,5 Various although rarely.12,13
studies like Weimin Xu et al, J Paweł et al, showed
female preponderance over males in acquiring thyroid Prevalence of the thyroid autoantibody positivity
disease, which was also noticed in our study.3,6 is relatively high worldwide. It is well-known that
in iodine-sufficient areas there is a higher rate of AT fostering formation of reactive oxygen species and other
prevalence than in iodine-deficient ones.14 Iodine intake free radicals, or the occurrence of oxidative stress. 26
is probably one of the most important factors that affects
thyroid autoimmunity and the incidence of AT.15 Lowered Vitamin E level is presumably due to its
use in preventing free radical damage that seems more
TPOAb and TGAb are two important thyroid extensive in thyroid dysfunction patients.27 Mano et
autoantibodies which are commonly found in patients al found in their study patients with various thyroid
with thyroid diseases. 16 As shown in some previous disorders that they presented elevated Vitamin E levels
studies, TPOAb is correlated with the severity of in their thyroid tissue.24 Researchers concluded that
lymphocytic infiltration and could induce antibody- Vitamin E acts as a scavenger in thyroid follicular cell
dependent cell-mediated cytotoxicity. 17,18 Boelaert K. dysfunction. Additional studies have demonstrated
et al.19 reported that TPOAb was dependently associated that active oxygen radicals inhibit the activity of an
with thyroid diseases, but little attention has been paid enzyme responsible for the conversion of T4 to the
to whether measuring other thyroid autoantibodies, in active hormone T3 and that sufficient Vitamin E levels
addition to TSH, could help predict thyroid nodules in may mitigate that effect.28 Present study also detects low
human populations.3 vitamin E levels in thyroid disorders.
Our results showed raised antiTPO and antiTG in Vitamin C is considered the most powerful natural
lymphocytic thyroiditis and papillary carcinoma which antioxidant29 which is capable of ‘’scavenging” reactive
were similar to the findings of M. Parham et al. 20 in oxygen species by reducing free radicals to more stable
Iran. They indicated that the different prevalence of species.30 Present study were in good agreement with
thyroid autoantibodies might explain the wide range of those obtained by Mohan et al.31 and Alicigüzel et al.32
the reported prevalence of thyroid nodules. In addition, as these studies described low levels of Vitamin C in
Eun Sook Kim et al.21 reported that TGAb was hyperthyroidism and increase oxidative stress at the
associated with an increased risk of thyroid cancer in same time, it also indicate that antioxidant vitamin
thyroid nodules. Similarly, other studies22,23 also showed become oxidized and it is eventually consumed in
an analogous association with malignancy by exerting its antioxidant action.
considering positive thyroid autoantibodies as a whole,
including TPOAb and TGAb.3
Conclusion
Oxidative reactions occur in all tissues and organs,
Present study concludes that autoantibodies levels
thyroid gland being one, in which oxidative processes
were raised in thyroiditis and papillary carcinoma
are indispensable for thyroid hormone synthesis. Both
thyroid indicating role of anti-TPO and anti-TG in
hyper- and hypothyroidism have been proven to promote
etiopathogenesis. vitamin C and E levels in various
cellular oxidative stress by influencing the intensity
thyroid diseases were variable.
of oxygen reactions and have been shown to affect
concentrations of the vitamins involved in scavenging Ethical Clearance: Taken from Institutional Ethical
of free radicals (usually decreasing their concentrations, Committee (IEC)
although study results differ) i.e. vitamins A, C and E9.
A study done by Salwa H. N. Al-Rubae’i and Abass K. Source of Funding: Self
Al-Musawi observed that there are marked variations in Conflict of Interest: Nil
vitamin A, E and C in both hypothyroidism as well as
hyperthyroidism.24
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DOI Number: 10.5958/0976-5506.2019.01584.5

Enhancement of Facial Aesthetics and Function in Posteriorly

Edentulous Mouth: An Orthognathic Surgical Case Report

Ashith M. V.1, Mustafa Khader1, Utkarsh Mangal3, Mithun K4

Reader, Department of Orthodonticsand Dentofacial Orthopedics Manipal College of Dental
1

Sciences, Mangalore, Manipal Academy of Higher Education (MAHE); 2Director, Kanachur Institute
for Craniofacial Anomalies, Mangalore; 3Consultant Orthodontist, Jaipur, Rajasthan; 4Assistant
professor Department of Orthodontics, A.J Institute of Dental Sciences, Kuntikana, Mangalore,
Karnataka, India

ABSTRACT
The goal of orthodontic treatment is to achieve a stable, functional result with enhanced aesthetics. In the
discussed case report, a case with skeletal class III malocclusion is presented with compromised periodontal
features and a bilaterally posteriorly edentulous mouth in upper and lower jaw. The case report highlights
the corrections achieved and their stability without the support and utilization of the posterior teeth,
otherwise deemed essential in the orthodontic treatment planning. The case is treated with orthognathic
surgery in upper and lower jaw to improve aesthetic balance of the face. With the use of position
screws, the case has been concluded displaying a stable occlusion with improved function. A four-year
follow-up and an important note on retention and stability is discussed in the following case report

Keywords: Skeletal Class III, edentulous, Orthognathic Surgery

Introduction aiming to improve self-esteem and achieve normal
occlusion and improvement of facial aesthetics. [2]
The goal of an orthodontic therapy is to achieve, a
stable, functional and esthetic result. Moderate to severe Surgical treatment of Class III malocclusion
malocclusion require a combined treatment approach includes, in most cases, mandibular setback, maxillary
of orthodontic and orthognathic surgery. The basic advancement, or a combination of both. The
objective of such malocclusions is to address the effectiveness of the surgical procedure depends on the
patient’s complaints, establish optimal functional occlusal stability achieved at the time of surgery and
outcomes, and improve aesthetics. afterwards. In this case, the patient does not have
posterior dentition which poses a challenge for the post
There are three main treatment options for
treatment stability. Therefore, the objective of this paper
skeletal Class III malocclusion: growth modification,
is to highlight a case of a skeletal Class III malocclusion
dentoalveolar compensation, and orthognathic surgery
[1]. After growth cessation, treatment of skeletal Class treated with orthognathic surgery, presenting with
bilateral posterior edentulous dentition.
III malocclusion in an adult requires orthognathic
surgery combined with conventional orthodontic Case History and Diagnosis: A male patient aged 26
treatment years and 1 month reported with the main complaint of
poor facial aesthetics associated with mandibular and
chin protrusion. On clinical examination, a concave
Corresponding Author: facial profile, maxillary hypoplasia, malar deficiency
Dr Ashith MV Reader with an acceptable facial proportion was observed.
Department of Orthodontics and Dentofacial Family history was also reported by the patient, with a
Orthopedics Manipal College of Dental Sciences, similar facial profile of his grandfather.
Mangalore
Manipal Academy of Higher Education, Intraoral examination revealed severely proclined
Manipal, Karnataka, India maxillary incisors and Class III canine relationships,
Phone: +919482246379
Email: [email protected]
306 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 306

posteriorly edentulous areas in all the four quadrants. Conted…

The retroclined mandibular anteriors showed slight
anterior crowding with a deviation of the mandibular N-B 2 mm -4 mm
midline to the right side by 3mm, and there was a 5 mm N-Pg 4 mm -3 mm
of negative overjet and an overbite of 0 mm. [Figure 1]. Vertical (skeletal and dental)
The above findings were corroborated by cephalometric N-ANS 47 mm 46 mm
assessment as seen in Table 1. The skeletal class III ANS-Gn 73 mm 67 mm
malocclusion can be attributed to the inherent (genetic) PNS-N 46 mm 41.5 mm
deficiency of mid face with a prognathic mandible. This Maxilla and Mandible
deficiency was further worsened by the loss of molars in ANS-PNS 41 mm 42 mm
all four quadrants, due to gross decay over the period,
Ar-Go 49 mm 43mm
resulting in the bilaterally posteriorly edentulous mouth.
Go-Pg 86 mm 81 mm
B-Pg 8.5 mm 5.5 mm
Table 1: Cephalometric analysis of the case
Ar-Go-Gn 155° 149°
Variable Pretreatment A-B Posttreatment
−6 2
Horizontal (skeletal) Max1-NF 122° 135°
N-A-Pg −5° Mand1-MP 71° 3.5 78°
SNA 83 Interincisal 78
124 138
SNB 85 angle 77
ANB -2 U1-FH 117 1 112
N-A -4 mm U1-SN 116 -1 mm 111

Figure 1: Pre treatment: Extra oral and intra-oral presentation before the treatment
Therefore, the patient was diagnosed as a case of to adapt the mandible, following BSSO setback (8mm),
skeletal dysplasia with class III incisor and skeletal in the desired occlusion.
relation with severe mid face deficiency, having
posteriorly bilateral edentulous dentition with difficulty Earlier case reports have discussed surgery in
in mastication. the edentulous mouths with use of implant supported
splints and use of modified gunning splints [3, 4, 5].
Treatment Objectives: The primary treatment However, in the present case report due to the support
objectives were to correct the Class III canine of the premolar and a bilaterally symmetrical occlusal
relationship, overjet, and overbite and specially to table, a conventional splint design with extent limiting
improve facial aesthetics. to premolars could be used successfully.
The complementary treatment objectives were to The surgical procedures included LeFort I
establish good functional and stable occlusion and to osteotomy, impaction and clockwise rotation of the
improve the smile characteristics and dental aesthetics. maxilla. This was performed to improve the maxillary
retrusion, and the clockwise rotation of the maxilla was
Treatment Plan: Control of periodontal disease was
done to improve the malar deficiency. A set back of the
required before orthodontic therapy could be started.
mandible with a bilateral sagittal split osteotomy to
The aim of the presurgical orthodontic preparation
improve the mandibular protrusion and establishan
was to correct the dental disharmonies. The presence
Angle Class I canine position with ideal overjet
of severe malocclusion, assessed through clinical
andoverbite. Genioplasty was performed to balance the
examination, displaying marked deficiency in malar
effect of the other facial osteotomy on the prominence
prominence, concave profile with steep anterior
of the chin.
divergence and a prominent chin projection, the main
goals of the orthodontic-surgical treatment were Rigid internal fixation with titanium plates
outlined as, maxillary impaction (5.5mm) and rotational and screws of 2 mm system was used without any
advancement(4.5mm) and mandibular setback(8mm), intermaxillary fixation. Due to the absence of posterior
by bilateral sagittal split osteotomy (BSSO). This was teeth, to facilitate settling of occlusion by is of elastics,
corroborated by cephalometric findings. [Table 1]. position screws were used. The position screws also aid
Once the orthodontic and orthognathic correction was in enhancing the fixation stability of miniplate systems.
done, the patient will be advised for rehabilitation of the [6] After the orthognathic surgery, orthodontic finishing
posterior dentition. was performed to obtain better teeth interdigitation. The
patient was instructed to wear vertical intermaxillary
Treatment Progress: After the moderate periodontal
elastics for nearly three months and gradually reducing
disease was brought under control. Preoperative
the wear time. Fixed canine to canine maxillary and
orthodontic preparation was conducted with preadjusted
mandibular lingual retainers were placed.
0.022 inch fixed appliances. Skeletal correction in this
case planned was mandibular setback and maxillary Treatment Results: The post treatment photographs
advancement. The required negative overjet was created show Class I canine relationship on both sides and
by controlled proclination of the lower anteriors. It was normal overjet and overbite. [Figure 2] Maxillary
done by inverting the lower incisor brackets. Leveling retrusion and mandibular prognathism were eliminated,
and alignment with Nitinol was done and stainless steel and facial aesthetics was considerably improved and
archwires of progressively increasing thickness were more over the patient was satisfied with his teeth, profile
performed. After leveling and alignment, 0.019 × 0.025- and smile line. The cephalometric measurements also
inch stainless steel rectangular archwires were placed showed maxillary advancement and mandibular set back
in the maxillary and mandibular arches in preparation contributing to improving the patient’s profile and his
for surgery. The presurgical orthodontic phase lasted for self-confidence level [Figure 3]. A mild midline shift
9 months. Following the completion of the orthodontic was observed, however as the patient satisfaction and
phase, surgical planning was done and two splints were acceptance to therapy was maximally achieved, hence,
made. The intermediate splint was fabricated to position further improvement was not considered. The case
the maxilla after the rotational advancement (impaction remained stable for four years after treatment with only
by 5mm and advancement by 4.5mm) and the final splint formation of a mild imbrication due to loss of
bonded
lingual retainer in lower arch and failure to follow up with the same. [Figure 4] The super imposition depicted the
changes in the maxilla and mandible. [Figure 5]

Figure 2: Post treatment: Extra oral and intra-oral presentation after the treatment

Figure 3: Roentgenographic records before and after treatment.

Figure 4: Follow up: Extra oral and intra-oral presentation 4 years after the treatment.
Figure 5: Superimposition tracing is depicting the changes achieved.
Discussion In the present case, the sagittal discrepancy was
attended by a high LeFort I osteotomy and rotation of
When the skeletal problem compromises the facial
the nasomaxillary complex. The rotational advancement
aesthetics, the surgical-orthodontic treatment is the most
of the maxilla was done to facilitate correction of
indicated for patients who do not present facial growth
the midface deficiency. This also contributes to the
potential. A correct diagnosis and planning, as well
correction of the inclination between the upper anterior,
as an appropriate execution of the treatment plan, are
which tend to be severely proclined in class III skeletal
determinant factors for having success and long-term
malocclusion. This step, also establishes the necessary
stability.
overjet for the effective mandibular setback, as required
From the sagittal standpoint, the parameters that in this case. The mandibular surgical correction was
indicate advancement of the maxilla with Le Fort planned with a combination of BSSO setback and an
I osteotomy are: flattening of the paranasal areas, advancement genioplasty. Here, the genioplasty helps to
accentuated naso-genial fold, moderate flattening of achieve a balance in the vertical and sagittal direction,
the cheek-bones, obtuse nasolabial angle, maxillary by establishing an aesthetic curvature, following the
prolabium little in evidence, prominent nose with some mandibular setback.
degree of hump and tip tilted downwards. Where a larger
increase in the middle third is necessary, Bell’s high However, If the maxilla is moved both forward and
osteotomy may be taken into consideration, because this rotated clockwise as in this case, the vertical component
[7]
provides greater filling at the cheek-bones . is likely to relapse, although the horizontal component
has a good chance of being retained. [9] This can be
The relationship between lips and teeth, gummy addressed with the use of rigid internal fixation and post-
smile if present, labial competence or incompetence, and surgical settling of occlusion.
the ratio between middle and lower thirds of the face, are
the fundamental parameters to take into consideration The severe mid face hypoplasia was attended to
for correction of vertical dimension. A vertical excess of by grafting in the malar region, with mandible cortical
the maxilla with labial incompetence, gummy smile, and grafts obtained following BSSO.
excessive tooth exposure tends to indicate repositioning
the maxilla superiorly.[8] But to achieve a stable occlusion in a patient
after orthognathic surgery with no posterior teeth is
challenging. Another significant difficulty faced is obtained, and this is perhaps the most important
during the period of orthodontic decompensation. As goal
the support from the posterior teeth is missing, the achieved, compliant with the patient’s chief concern.
stabilization of forces, falls largely on the anterior
teeth, during the function. Therefore, the maintenance Conflict of Interest: None
of the stable occlusion was achieved with the help of a
Source of Funding: The present case report obtained no
combined approach with both surgical and orthodontic
external source of funding, apart from the support of the
treatment, which led to a significant facial, dental, and
authors’ institution.
functional improvement.
Ethical Clearance: Ethical clearance was obtained from
Skeletal Class III malocclusion treatment is difficult;
the Institutional ethical committee ethical clearance from
however, an orthodontic-surgical approach for the
the institutional ethical committee (Protocol Number:
correction of this alteration has wide acceptance among
18088), Manipal Academy of Higher Education
patients [10]. When aesthetics is compromised, only an
(MAHE), India.
orthodontic treatment is not enough. In these cases, it
is necessary to combine orthodontics and orthognathic
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DOI Number: 10.5958/0976-5506.2019.01585.7

A Study on Development of Processes for Verification and

Validation in Medical Device Domain

P. Shireesha1, P. Niranjan2
1
Associate Professor, 2Professor, Kakatiya Institute of Technology & Science, Warangal,
India

ABSTRACT
Medical device producers are discovering an enhancing demand to integrate the research ideas and
results from traditionally separated research study locations such as medicine, software and also
system engineering, and also mechanical engineering. In 2006, we carried out a study with greater
than 100 firms from Europe and also the US to the present condition of the combination of software
engineering modern technologies right into the medical device domain. The first outcomes of this
study exist in this paper. Both software designers, as well as the medical device sector, can make use
of these searchings for to much better recognize present difficulties as well as future instructions,
to attain a much better combination of the areas. This study is based upon an evaluation of readily
available literary works in the area of confirmation and also recognition in common software
advancement, safety-critical as well as medical device software domains.

Keywords: Medical device software, Medical device standards, verification,

validation
Introduction items. This evaluation, from June 2006, reveals that
21% of the medical device style failings are triggered by
Today, several medical gadgets cannot accomplish
software problems [6]. This is a boosting fad, because of
their planned usage without the software ingrained
the very same numbers from November 2005 program
within them, which carries out a selection of features
software in charge of 17% of building and construction
and also attributes. Studies of fads in the medical device
as well as layout problems.
market suggest that software is just one of one of the
most definitive elements for creating cutting-edge items Provided this context, and also the basic absence
with brand-new capacities, as well as anticipate that the of empirical understanding concerning the state of
significance of software will just additionally enhance the technique relating to medical device software
in the future [4] Research studies likewise anticipate that advancement, we made a global study. Our goal was
the r & d (R&D) financial investment in software in this to recognize the present objectives as well as problems
market will certainly boost to 33% of the general budget of business in this market as well as exactly how they
plan by 2015 [2] pick software methods to resolve the problems that they
see. We had an interest in recognizing the level to which
As the duty of software in the medical device
the requirements that have actually been created have
domain enhances in value, so do the failings as a result
actually been identified as well as instantiated by sector.
of software problems. An evaluation of medical device
In addition, we had an interest in evoking one of the
remembers by the FDA in 1996 [5] discovered that
most crucial difficulties relative to creating ingrained
software was significantly in charge of item remembers:
software for medical functions. These outcomes can
In 1996, 10% of item remembers were triggered by
be made use of by scientists as well as specialists to
software-related problems. This was up from 6% in the
obtain an introduction of the degree of use of different
years 1983-- 1991. A German study on medical device
procedures as well as devices in the domain in addition
remembers in the medical field shows that software is
to recognizing beneficial targets for establishing brand-
the leading reason for threats associated with building
new methods as well as techniques targeted at more
and construction as well as layout flaws of medical
boosting software top quality in the medical industry.
device
313 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 313

The primary tasks of confirmation and also locations regardless of the classification they fall
recognition are testimonials and also screening. under. These procedures consist of Project Preparation,
Software screening cannot be performed up until Dimension & Evaluation and also various other
the software is developed. Given that mistakes assistance procedure locations. The confirmation
require to be discovered early, software examinations procedure is made use of to confirm the job items
are performed prior to the item has actually been produced from the efficiency of these procedures.
executed[6]. The distinction in between recognition as Confirmation is additionally made use of thoroughly in
well as confirmation can be discussed by considering the context of the engineering procedure locations that
the function of the examinations executed. Making includes Needs Monitoring, Needs Growth, Technical
use of models to evaluate if demands can be resolved Option and also Item Combination. The version likewise
is an instance of a confirmation technique. The offers assistance in regards to instances of approaches
examination of a model by the individuals to check like peer evaluations, declaration protection screening,
if the item meets their demands is an instance of a and also branch insurance coverage screening that might
recognition technique. Simply put, we can state that be made use of in this context.
the confirmation should ask-- Are you satisfying the
specific demands? as well as-- Are you constructing the The recognition procedure location incrementally
item right? Similarly we can state that the recognition verifies items versus the consumer’s requirements.
should ask-- Are you satisfying the functional Recognition might be executed in the functional setting
demand? -- Does this item satisfy its designated usage or substitute functional setting. Control with the client
in the designated atmosphere? Are you constructing on the recognition demands is a crucial component of
the best item? [8] ANSI/IEEE Sexually transmitted this procedure location. The range of the recognition
disease 1012 [9], Criterion for Software Confirmation procedure location consists of recognition of items,
as well as Recognition Program supplies a collection item elements, picked intermediate job items, and also
of minimal V&V jobs for every of the lifecycle stages procedures. These verified aspects might usually call for
in a software project. re-verification and also revalidation.
Verification and Validation in Generic Software Several of the essential distinctions in between
Development: 2 crucial referral versions which are safety-critical criteria and also generic-software growth
extensively made use of in the context of software standards/models highlighted in our study were as
procedure renovation are the Ability Maturation adheres to.
Version ® Integrated (CMMI ®) as well as
ISO/IEC Recognition tasks can be related to all elements
15504-5. They resolve the software confirmation as of the item in any one of its desired settings, such as
well as recognition procedures in the complying with procedure, training, production, upkeep, and also
means: CMMI ® according to ANSI/IEEE Sexually assistance solutions. Like the confirmation procedure
transmitted disease 1012-1986 suggests a lifecycle location, recognition is additionally executed throughout
sight for confirmation as well as recognition tasks. It the training course of the item growth as it relocates
specifies confirmation as-- Verification that function from each stage of the lifecycle. As an example in the
items effectively mirror the demands defined for them. needs stage, the version recommends an evaluation,
To put it simply, confirmation makes sure that ‗ you simulations, prototyping and also demos as feasible
constructed it right’ and also recognition as-- strategies for recognition. Both recognition and also
Verification that the item, as supplied (or as it will confirmation tasks frequently run simultaneously and
certainly be given), will certainly accomplish its also might make use of sections of the exact same
designated usage ‖. As a result, recognition makes sure setting.
that you developed the appropriate item’. The
confirmation and also recognition procedures become In ISO/IEC 15504-5, the objective of the
confirmation procedure is to verify that each software
part of the engineering refines group, as well as both, are
job item and/or solution of a procedure or project
level 3 procedure locations in the organized version.
correctly mirrors the given demands. The jobs
The confirmation procedure location in CMMI ® concerning confirmation consist of the growth of a
is utilized by a number of the various other confirmation method, advancement of requirements for
procedure confirmation,
doing the task of confirmation, the decision of activities system researchers. It appears that software is an integral
based upon confirmation outcomes and also making the part in several medical gadgets: 98% of the business
outcomes readily available to the stakeholders. price software as either an extremely crucial (84%) or
essential (14%) element of their items. The number
Risk Management: Risk Management entails the
additionally shows that software is security- important
recognition as well as administration of threat. Threat
aspect of the item in over 75% of the instances. On the
analysis is a feature of influence and also the chance of
other hand, for just 16% of the firms does the software
an event. A danger based strategy to security enables the
plainly understand non-safety-critical capabilities.
dangers related to a system to be recognized and also
focused on. The danger evaluation entails estimation of Inquired about several of the viewed difficulties,
degree of threat connected with a danger. 64% of our individuals kept in mind that discovering
enough software programmers (i.e., personnel with a
Independence in Verification and Validation: The
computer technology history) is an obstacle. At the exact
IEEE Criteria for Software Confirmation and also
same time, a lot of problems relating to software top
Recognition state that classic Independent Confirmation
quality originate from tasks associated with preparing
and also Recognition (IV&V) is typically needed for
the software, the capability it ought to achieve, and
the advancement of software systems considered--
important ‖ in nature, i.e., those which can lead to death, also exactly how it will certainly achieve it. That is,
objective or considerable social or economic loss. The many obstacles come from needs tasks (63%) as well
outcomes of a research [7] highlight the distinction in as style and also layout tasks (16%). In fact, executing
mistake discovery abilities in between 2 techniques-- the software code is viewed as one of the most difficult
non-independent V&V as well as Independent V&V tasks by just 10% of the participants. This suggests that
(IV&V). The outcomes suggest that IV&V supplied financial investments in demands engineering tasks
a considerable value-added element to the software appear to be most appealing to acquire considerable
advancement procedure. Self-reliance is a crucial aspect enhancements in the software growth procedure.
attended to by DO- 178B as well as provides certain
Searching in even more information moot that
support on the topic.
creates troubles for every kind of task, for requirements-
ISO/IEC15504 -5 and also Automotive related tasks 86% of the business view transforming
SEASONING state that-- levels of freedom ‖ is requirements as the main problem. Missing demands
something each project needs to prepare as a component (33%), as well as misunderstanding needs (39%), are
of its confirmation as well as recognition technique. The likewise viewed as vital.
FDA GPSV addresses freedom in Area 4.9, however,
Connected to style as well as layout, the major
leaves it to the discernment of device producers on just
obstacle is missing out on details in the layouts (53%)
how this is to be accomplished. ISO/IEC 62304 does not
and also incongruities in between the intended style as
mandate self-reliance. Freedom is attended to in
well as the software (39%). Missing out on possibilities
ISO
to recycle software code in an organized method (33%)
13485 in area 5.5.1 - Obligation as well as Authority,
where it mentions:-- Leading monitoring will develop as well as problems in preserving the software code
the connection of all workers that handle, execute as (29%) are regarded as the major concerns throughout an
well as validate job influencing high quality, and also application.
will make sure the self-reliance as well as authority Figure 1 programs that around 50% of the business
essential to do these jobs. adhere to a specified procedure to execute the tasks
Characterizing software development in the pointed out over often, that is, they stated that they
organization: Individuals were asked to define the constantly or often adhere to such a procedure. (If the
academic history of most of the participants of their requirements are loosened up to consist of firms that
software advancement group. These programmers comply with specified procedures in regarding fifty
originate from techniques such as electronic devices, percent of their tasks after that 78% of the participants
medical scientific researches, or electric systems had actually a specified procedure for execution, 71%
engineering. Just in 36% of the instances in the medical had one for style, as well as 69% had one for needs)..
device software developed primarily by computer
Characterizing the challenges of using notations temporal reasoning, style summary languages) defining
and tools: For design as well as layout, architectural software needs or designs were hardly ever used. For
layouts are one of the most often used symbols for instance, for defining software demands in addition to
modeling the software. These representation kinds design as well as layout, just 2% of the firms make use
(e.g., course layouts, bundle representations, practical of official languages in all of their jobs. In 22% of the
block layouts) are made use of by 64% of the business firms, official languages are utilized regularly in the
often (constantly or regularly used). Series and also demands stage and also in 14% of official languages
information circulation representations appear to have are utilized regularly for design as well as style.
a reduced value. These layouts are regularly utilized by
40% and also 36% of the business, specifically. Extra Subsequently, much less official symbols and also
official symbols such as state graphs and/or Time Petri languages are most preferred for usage in all kinds
Nets appear to be of reduced relevance in the medical of tasks. Figure 2 reveals the outcomes for needs
device domain. State graphs are made use of regularly engineering. There, all-natural language (e.g., English
by 23% of the business, while Time Petri Webs are not or German) is made use of in nearly all business in all
used on a regular basis by any kind of participant. Just tasks. In 92% of the business, this type of symbols is
6% of the firms periodically (i.e., much less after that utilized constantly or regularly.
half the moment) utilize these symbols
A comprehensive evaluation of the responses
In order to record the outcomes of the different tasks discloses that for 46% of the business all-natural
associated with creating software, various symbols, as language is the only symbols to define demands.
well as languages, can be used. The majority of our Structured symbols such as usage instances are utilized
participants were utilizing reasonably casual symbols by 40% of the business often (i.e., constantly or
as well as strategies to do so. Official languages regularly utilized).
(e.g.,

Figure 1: Defined processes for development activities

Figure 2: The usage of natural language in the requirements phase

Figure 3: Usage of tools for different activities
Conclusion Journal of the European Union, September
2007. [Online]. Available: http://eur-lex.
Research studies like the study explained in
e u r o p a . e u / L e x U r i S e r v / L e x U r i S e r v. d o ?
this paper can assist to recognize concentrates for
uri=OJ:L:(2007):247:0021:0055:en:PDF
enhancements as well as enable ambitious activities
to even more incorporate software engineering 4. IEC 62304 - Medical device software - Software
techniques, methods, devices, as well as criteria lifecycle processes, International Electrotechnical
right into the medical device domain. The locations Commission Std., ( 2006).
we have actually recognized for enhancement will 5. U.S. Food and Drug Administration (FDA),
certainly give advice for the meaning of the V&V “General principles of software validation; final
procedures in Medi FLAVOR. Better to the meaning guidance for industry and fda staff, version 2.0,”
of a collection of procedures and also the linked (Jan. 2002). [Online]. Available: http://www.
techniques pertaining to V&V, the procedures need fda.gov/MedicalDevices/Device Regulationand
to be piloted in companies within the medical device Guidance/Guidance Documents/ucm085281.htm
software growth market.
6. R. Jetley, S. Purushothaman Iyer, and P. Jones,
Ethical Clearance: Not Required “A formal methods approach to medical device
review,” Computer, (April 2006).vol. 39, no. 4,
Source of Funding: Self pp.
61–67,
Conflict of Interest: Nil
7. E. B o¨ rger and R. F. Stark, Abstract State
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DOI Number: 10.5958/0976-5506.2019.01586.9

A Technique for Network Design and Requirements for

Medical Sensors

V. Chandra Shekhar Rao1, P. Niranjan2, A. Sowmikadurga3

1
Associate Professor, Department of CSE, 2Professor of CSE, 3M.Tech Scholar, Kakatiya institute
of technology and science, Warangal

ABSTRACT
In recent days, a large component of people relies on readily available material in social networks in their
choices (e.g. testimonials and also comments on a subject or item). The opportunity that anyone can leave a
testimonial supply a gold possibility for spammers to create spam testimonials concerning product or
services for a variable rate of interests. Determining these spammers and also the spam web content is a
warm subject of research study and also although a substantial variety of research studies have actually
been done just recently towards this end, however up until now the approaches presented still hardly find
spam evaluations, and also none reveal the relevance of each drawn out function kind. In this research, we
suggest a unique structure, called NetSpam, which uses spam attributes for modeling testimonial datasets as
heterogeneous information networks to map spam detection treatment right into a classification trouble in
such networks. Utilizing the significance of spam attributes aid us to acquire much better cause regards to
various metrics explored on real-world testimonial datasets from Yelp as well as Amazon.com internet
sites. The outcomes reveal that NetSpam outshines the existing approaches and also amongst 4 groups of
functions; consisting of review-behavioral, user-behavioral, evaluation etymological, individual-
etymological, the remainder kind of attributes does much better than the various other classifications. It
additionally concentrates on providing the current improvements in both wearable and also implantable
innovations. In addition, this paper deals with the challenges that exist in the different Open Solutions
Affiliation (OSI) layers and also shows future research study locations worrying about the usage of cordless
sensors in healthcare applications.

Keywords: Network, NetSpam, sensors, healthcare.

Introduction possibility for spammers to create phony testimonials
developed to misguide customers’ point of view. These
Online Social network sites play an influential duty
deceptive testimonials are after that increased by the
in information proliferation which is thought about as a
sharing feature of social networks and also proliferation
crucial resource for manufacturers in their ad campaign
over the internet. The evaluations contacted alter
along with for clients in choosing services and products.
customers’ assumption of just how excellent an item or a
In the previous years, individuals count a great deal
solution are taken into consideration as spam [10], as well
on the composed evaluations in their decision-making
as are typically created in exchange for loan.
procedures, and also positive/negative testimonials
encouraging/discouraging them in their option of Existing System: In Existing work, the job just
product or services. Furthermore, composed testimonials relies on the discover the spam testimonials and also
additionally assist the company to boost the high quality spammers. None reveal the relevance of each removed
of their product or services. These evaluations hence function kind. On the various other hands, a substantial
have actually come to be a vital consider success of quantity of literary works has actually been released on
an organization while favorable testimonials can bring the strategies made use of to determine spam as well
benefits for a firm, adverse testimonials can possibly as spammers along with various sort of evaluation on
influence integrity as well as create financial losses. The this subject. These strategies can be identified right
truth that any individual with any type of identification into various groups; some making use of etymological
can leave remarks as a testimonial, gives an patterns in message which are primarily based upon
alluring
318 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 318

bigram, and also unigram, others are based upon the apparent detectives or, on the various other hand
behavior patterns that count on attributes removed from clients.
patterns in individuals’ habits which are mainly
metadata based.

Proposed System: We suggest NetSpam framework

that is a unique network-based technique which versions
evaluate networks as heterogeneous information
networks. The basic principle of our recommended
structure is to design a provided evaluation dataset as
a Heterogeneous Information Network (HIN) and also
to map the trouble of spam detection right into a HIN
category trouble. Specifically, we design evaluation
dataset as a HIN in which testimonials are linked
with various node kinds (such as attributes as well as
individuals). A weighting idea is after that used to
determine each attribute’s value (or weight). These
weights are made use of to compute the last tags for
evaluations making use of both not being watched and
also monitored strategies.

Literature Survey: According to RAYMOND Y.

K. LAU, S. Y. LIAO, as well as RON CHI-WAI
KWOK, ANQUAN XU, YUEQING XIA, YUEFENG
LI, Online Social network sites, play an influential
duty in information proliferation which is taken into
consideration as a crucial resource for manufacturers in
their ad campaign along with for consumers in picking
services and products. In the previous years, individuals
count a whole lot on the created testimonials in their
decision-making procedures, and also positive/negative
evaluations encouraging/discouraging them in their
option of services and products. Furthermore, created
evaluations likewise assist the company to boost the
high quality of their product or services.

According to Paulo Cortez, Clotilde Lopes, Pedro

Sousa, Miguel Rocha, Miguel Rio, In this Mark removal
arrange isolates each HTML tag, modifications overall
location names to <mytext> and also triggers an
academic e-mail representation. Call reordering phase
administers early setting to all marks and also
determinately signing up with phase sets up the catch
established names to create the perfect e-mail factor to
consider. The standard emphasis of adding phase is to
minimize the possibility that pork is prosperously
arranged with exposed spams when the mark size of an
e-mail idea is brief.

According to M. Bellare, S. Keelveedhi, as well as

T. Ristenpart, Initially, utilizer gets in the location of the
motion picture for obtaining the evaluations provided by
319 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 319
1. After going into the job of the movie, API obtains
the website of movie testimonial as well as obtain
every one of the reviews of the motion pictures
providing by the locations.
2. Afterward, packaging figuring is implemented for
loading the testimonials in the parties.
3. After coming to cycle the course towards
clustering, the ARFF document is created, this
ARFF record has the attributes needed for
identifying the perfect evaluations and also
circumstances of the above top qualities. This
ARFF has variety of residential or commercial
properties like is enigma show up in the evaluation,
Resources word in research study, restriction, signs
up with, evaluation, and so on.

Requirements for Wireless Medical Sensors: In

order to feel organic information from the body and
also send it wirelessly over a brief range, wearable
and also implantable sensors are used. These sensors
connect the obtained information to a control gadget
endured the body or put in an obtainable area. After that,
the information constructed from the control tools are
communicated to remote locations in a cordless body-
area network for analysis and also healing functions
by including various other cordless networks for long-
range transmissions[5].. Particularly, sensors made use of
in cordless networks for healthcare applications need to
please the list below demands:

Interoperability: Interoperability in healthcare is the

level to which numerous systems and also gadgets
can analyze information as well as present it in a
user-friendly means. This involves that information
exchange techniques will certainly permit information
to be shared throughout medical facilities, drug stores,
laboratories, medical professionals as well as people, no
matter which supplier is made use of. The major purpose
behind interoperability is to change the disorderly and
also sometimes useless nature of information exchange
amongst healthcare facilities. Via interoperability,
information ends up being extremely mobile. Individual
health and wellness information became part of a system
as soon as, appears to clients anywhere they are and also
whenever they require it [10].

Dependable Interaction: For medical applications that

count on WBANs, the integrity of the interaction web
link is of vital value. The interaction restriction ranges
nodes given that the tasting prices called for by
each
sensing unit are various. For instance, as opposed to Based, Evaluation Based spam detection designs.
sending out raw electrocardiogram (ECG) information Utilizing monitored methods admin will certainly do
from sensors, we can execute attribute removal on weight estimations.
the sensing unit, as well as transfer just information
concerning the specific occasion. Along with lowering User Module: User is the end user of our application,
the high needs on the interaction network, the minimized and we can also consider e-commerce user. User can
perform search products, buy products, and submit
interaction demands conserve complete power expenses,
rating and review for products. This data will deliver to
and also subsequently boost battery life. A cautious
admin, and this data will be our dataset to our
compromise in between interaction and also calculation application.
is essential for optimum system style [9].
Heterogeneous Information Network (HIN): This is
Implementation mapping the issue of spam detection right into a HIN
category trouble. Specifically, we design testimonial
Admin Module: Admin is the primary individual of our
dataset as a HIN in which evaluations are attached
application after login admin can add/delete items for via various node kinds (such as Individual-Based,
individual purchasing and also gather the individual’s Testimonial Based). A weighting formula is after that
testimonials. After admin can carry out spam detection utilized to compute each attribute’s value (or weight).
for utilizing not being watched designs. In not being These weights are made use of to compute the last tags
watched versions admin will certainly do Customer for evaluations utilizing both without supervision as
well as monitored strategies.

Results

Figure 1: Home Page

Figure 2: Admin Pages

Figure 3: User Pages

Figure 4: Payment Page

Figure 5: User orders

Figure 6: Rating & Reviews page
Conclusions have actually gotten substantial interest from numerous
techniques for over a year, information diffusion and
This research study presents a unique spam
also web content sharing in multilayer networks is still a
detection structure particularly NetSpam based upon a
young study. Dealing with the trouble of spam detection
meta path principle along with a brand-new graph-based
in such networks can be taken into consideration as a
approach to identify testimonials depending on a rank-
brand-new study line in this field.
based labeling technique. The efficiency of the
recommended structure is examined by utilizing 2 real- Ethical Clearence: Not Required
world identified datasets of Yelp and also
Amazon.com web sites. Our monitorings reveal that Source of Funding: Self
determined weights by utilizing this meta path idea can Conflict of Interest: Nil
be extremely reliable in determining spam evaluations
and also brings about a far better efficiency.
Furthermore, we located that also without a train References
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executes much better than previous jobs, with just a 07-30.
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AUC along within the computed weights. The outcomes 3. M. Ott, Y. Choi, C. Cardie, and J. T. Hancock.
likewise confirm that making use of various guidance, Finding deceptive opinion spam by any stretch of
comparable to the semi-supervised approach, have no the imagination.In ACL, 2011.
visible impact on establishing a lot of the heavy 4. Ch. Xu and J. Zhang. Combating product review
attributes, equally as in various datasets. For a future spam campaigns via multiple heterogeneous
job, meta path principle can be put on various other pairwise features. In SIAM International
issues in this field As an example, a comparable Conference on Data Mining, 2014.
structure can be made use of to find spammer areas. For
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with team spammer functions and also evaluations with In WSDM, 2008.
the greatest resemblance based upon metapth idea are 6. F. Li, M. Huang, Y. Yang, and X. Zhu.
referred to as neighborhoods. Additionally, using the Learning
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to identifying spammers and also spam evaluations. Intelligence; IJCAI, 2011.
Additionally, while solitary networks
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Castellanos, and R. Ghosh. Exploiting burstiness S. Guah, K. P. Gummadi, B. Krishnamurthy, and
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In ICDM, 2014.
DOI Number: 10.5958/0976-5506.2019.01587.0

Breast Self-Examination and Clinical Breast Examination:

Knowledge, Practice, and Awareness Towards Breast Cancer
among Females in and around Mangaluru

Sadhwi1, Gayathri M Rao2, Aradhana M3, Saritha Kamath U4

1
2nd MBBS Student, 2Associate Professor, 3Tutor, Department of Biochemistry, Kasturba Medical College,
Mangalore, 4Associate Professor, Dept. of MLT, Manipal College of Health Professions, Manipal
Academy of Higher Education, Manipal , Karnataka, India

ABSTRACT
Introduction: Among the Indian women, the second highest cause for cancer related vulnerability is due to
breast cancer development. According to the literature survey, though there are several contributing factors
underlying the development of Breast Cancer, One of the important causes is the lack of knowledge towards
the identification.
Materials & Method: The present study was to reveal the level of knowledge towards Self- breast
examination and clinical breast examination, among 214 females belonging to the age group from 18 to 65
years, in around mangaluru, with different levels of literacy, economic status, social exposure and field of
occupation using questionnaire. Study report shows that the extent of knowledge is around 36% and shows
no relation to the extent of literacy levels.
Results: The results of the study showed that 97% of the participants said that they had heard about
breast cancer and their sources of information were mainly health professionals/workers (98.2%), friends/
neighbors (83.5%), TV/Radio (76.0%) and printed materials (60.2%). Of the participants, 12% reported
positive family history of breast cancer. 35.68% said that they have heard about BSE, among these, 72.2%
were regular performers with complete knowledge of BSE, 27.80% knew the procedure but were irregular
in practice. Moreover, 85.5% does not know who has to do Clinical Breast Examination and 71.5% of the
participants were unaware of mammogram.
Conclusions: The study points to the insufficient knowledge of the study population about breast cancer
and
identified the negative influence of low knowledge of the practice of BSE.

Keywords: Breast cancer, Clinical breast examination, Breast Self

Examination
Introduction and mortality rate. Study data shows that the occurrence
of breast cancer varies among countries with highest rates
Breast Cancer is the most sensitive and extended
in the United States and Canada and the lowest in Asia.
issue affecting women globally with expanded rootlets.
Even though it is said that prevalence of BC is more in
Researchers are attempting to unravel the causes and
developed countries, around 50% of breast cancer
consequences of Breast Cancer to reduce the
patients and 58% of deaths seen in less developed
sufferings
countries.1

There is a burning need to educate the society to

Corresponding Author: know the risk factors, signs and symptoms of the
Dr. Gayathri M Rao disease. Because of the diversity in socio-demographic,
Associate Professor, Department of Biochemistry economic, educational, lifestyle, etc. the exposure
Kasturba Medical College, Mangalore, towards the knowledge remains divergent. The risk
Manipal Academy of Higher Education factors includes genetic Consensus document for
Phone: 9448951498 management of breast cancer. Indian Council of
Email: [email protected]
Medical Research 2016. background -family
history/genetic mutations, life style,
324 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 324

age, pregnancy/lactation.2 Along with other A pilot study is carried out with small group (n=20)
pathological/ physiological risk factors, lack of to improve the clarity, validity and applicability of the
knowledge also one of the important causes to increase questionnaire to improve the outcomes to facilitate the
the rate of sufferings. Several measures to promote BC
data collection. All information about the individual
control and decrease mortality rate includes programs to
kept confidential.
develop awareness and knowledge, early
detection/diagnosis, treatment ant and palliative care. Subjects of the Study: Total number of participants
Long term preventive actions may be the lifestyle were 214.Women between 18-60yrs. with different
modifications. Although many preventive and risk
background including staff and students from
reducing measurements are in action 3, still low and
educational institutions, Bank employees, house wives
middle income countries have majority of the breast
and housekeeping staff in and around Mangaluru.
cancer cases.
Information is collected by distributing the questionnaire
Education and screening are the major preventive after obtaining the informed consent for willingness to
measures under action to control the disease in most participate in the study.
developed countries. Earlier the detection, better and
effective measures can be taken and which will improve Exclusion Criteria: Those who are diagnosed with
the survival rate also. The early detection includes breast cancer
some screening methods such as performing/practicing
BSE regularly. Though mammography is the most All the necessary ethical approvals carrying out the
reliable method people hesitate because of its high cost. study is obtained from institutional ethical committee,
Even in developing countries BSE is recommended 4. Ref No. IEC KMCMLR 03-18/46.
According to the several earlier studies, the % of regular
Statistical Analysis: Data analysis was done by ELR
BSE performers is very less 5, 6 which could elevate the
software. Variables were categorized by percentage
burden.
distribution.
Thus, this project is aimed to work with society, to
identify the extent of knowledge towards breast cancer Result
with the help of questionnaire including the risk factors,
self-breast examination, clinical breast examination and Socio-demographic status of participants showed in
its significance. Questionnaire was derived from other the Fig.1& 2.Among the participants, 12% of females
published studies dealing with the same topic.7-9 Early were homemakers, all other participants were in
detection leads to higher probability of getting treated different working category, including bank employees,
effectively at the earliest. This study aims at taking the technical workers, teachers and housekeeping staff.
women out of their veils and pay attention to the risk
factors and perform screening tests regularly.

OBJECTIVE: To gather information about the

knowledge of Breast Cancer, Self breast examination
and clinical breast examination among women in and
around Mangaluru.

Methodology

A predesigned questionnaire will be used to check

the knowledge, awareness, risk factors, screening
methods towards breast cancer and other screening
methods. A semi-structured questionnaire covering
socio-demographic information, knowledge and attitude
Fig. 1: Source of knowledge
of the respondent.
Less than

Fig. 2: Educational level

7% had reported the BC cases in their family (2%) & friend circle (5%). Rest of the study results are as follows
in Table No.1 & 2

Table No. 1: Awareness, practice and importance of breast self-examination among participants
Knowledge/Practice Response Frequency Percentage (%)
Yes 76 35.68
Heard of BSE
No 137 64.32
Known it is useful in the detection Yes 48 22.54
of BC No 176 77.46
Weekly 4 1.8
Monthly 17 7.98
How often BSE to be done
Yearly 14 6.57
Don’t Know 178 83.57
During menstruation 4 1.8
Few days after menstruation 10 4.69
Best time to do BSE
Breast feeding 3 1.41
No idea 196 92.02
Yes 36 16.98
Know how to do BSE
No 176 83.4
Yes 36 16.9
Regular 26 72.2
BSE performers
Irregular 10 27.8
Not 177 83.1
New all 14 6.54
Knowledge about the changes can
Partially known 59 27.57
be observed in the breast cancer
Don’t Know 141 65.89
Fig. No.3: Knowledge towards the changes in the breast during cancer development

In the present study, among the participants, 14 had good knowledge about the changes, 59 had partial
knowledge (one/multiple symptoms) and141 did not had any knowledge about the changes which may lead to breast
cancer.

Table No. 2: Awareness, knowledge and importance of Clinical breast examination among participants
Knowledge/Practice Response Frequency Percentage (%)
Yes 59 27.7
CBE is useful in BC detection
No 154 72.3
Doctor 43 20.19
Trained nurse 1 0.47
Who has to do CBE
Individual 4 0.94
Don’t Know 167 78.4
Weakly 1 0.47
Monthly 8 3.76
How often should CBE done yearly 19 8.92
When abnormality found 4 1.88
No idea 181 84.98
Yes 58 27.23
Heard of mammogram
No 153 72.27
Puberty 3 1.41
20yrs 44 10.33
From which Age mammogram
Yes 18 8.45
should be started
After menopause 3 1.41
No idea 167 78.4
Discussion some screening methods such as performing/practicing
Education and screening are the major preventive BSE regularly and is of no cost, non-invasive method.
measures under action to control the disease in most Though mammography is the most reliable method
developed countries. Earlier the detection, better and people hesitate because of its high cost. Earlier studies 10
effective measures can be taken and which will improve have identified several barriers which will hinder the
the survival rate also. The early detection includes early detection of BC.
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DOI Number: 10.5958/0976-5506.2019.01588.2

Emotional Intelligence Level of Students and Mental Ability

Belonging to Rural and Urban Backgrounds

Shailaja Sangaraboina
Assistant Professor, Department of English, S R Engineering College, Warangal

ABSTRACT
The students originate from different histories such as rural as well as urban areas. The students undertake a
great deal of stress to withstand today’s competitors, primarily currently of their facility phase in
occupation. In order to deal up with the tension as well as stress these days affordable globe, the students
must have an equilibrium in their psychological security. Emotional Intelligence is a kind of intelligence
that has actually been greatly researched in social scientific researches, psychology and also service field,
yet not in the instructional field. The here and now research aids us to learn about the emotional
intelligence degrees of students in the message college graduation particularly the students originating from
rural and also urban areas. It is relative research of emotional intelligence degrees of students coming from
rural and also urban histories, to ensure that it is practical to evaluate the student’s emotionality, wellness,
sociability as well as self-control.

Keywords: emotionality, Mental Ability, Emotional

Intelligence
Introduction An emotional intelligence quotient, or EQ, is the
brand-new term which is being made use of a growing
The economic climate has actually ended up being
number of in the personnel’s divisions and also it is
international which is driven by advancements and
additionally making its trip in the direction of the exec
also innovation and also Organizations need to change
board areas. This post will certainly offer necessary
themselves to offer brand-new consumer assumptions.
info on what EQ is exactly how it is various from
Today’ economic climate is considerably really unsure
individuality, and also just how it has actually confirmed
with difficult chances. It is based upon ability expertise
to affect the rural and also urban students in their
as well as efficiency driven. To be an effective leader the
scholastic efficiency.
here and now circumstance needs regard, engagement,
empowerment, synergy as well as self-administration. Emotional Intelligence (EQ) is the arising principle.
With the above difficulties, a brand-new type of leader There is a debatable inquiry emerging from lots of
is required to lead service via disturbance. Today’s scientists whether the EI can be found out as well as
Supervisors in their companies do this job. It’s being educated as well as whether this EI will certainly aid the
extensively thought by the public that psychological students’ to prosper in college and also in life.
and also social capability is as essential, or perhaps
more crucial, than typical measurement of intellectual EI is the idea which is extremely functional in
capability and also individuality . Emotional
[3] nature as well as appears to be extremely vital for the
intelligence is specified as “the composite collection of growth of human life. The scientists still rely on the
abilities that make it possible for an individual to handle ideology that intelligence, as well as success, are
himself/ herself as well as others”. The relevance of symmetrical to each other now they are not seen
Emotional Intelligence is significantly being similarly. The outcomes of the students are not due to
acknowledged and also examines throughout numerous the inconsistencies from the essentials. The here and
occupations. Taking care of feelings in social contexts now day concentrate on the success of the student not
are plainly crucial for success in a range of social; in just on their thinking abilities too on the self-
addition to career-related domain names. understanding, feelings, and also social abilities.
330 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 330

In the last 20 years, Numerous Knowledge concept checked out the effect of emotional intelligence on
[9]

was presented by Howard Gardner in 1983 as well as the effective shift from senior high school degree to the
the Emotional Intelligence concept by Bar-On[5]. This college degree. The outcomes of their research disclosed
concept of emotional intelligence provided a brand-new that academically effective students had significantly
facet that the intelligence quotient (INTELLIGENCE) greater degrees of numerous various psychological as
is not the only step for success. Emotional intelligence well as social proficiencies. From this research, they
is the middle of estimates with the sight factor of determined the significance of emotional intelligence in
education and learning which highlights the very best in the effective shift of students from secondary school to
students not only simply in scholastic success. It defines college.
that the EQ proficiencies are required to improve the
individual abilities resulting in success in academics. Mestre[10] carried out a study on 127 Spanish
The students that are exceptional academically appear teens, the capacity to comprehend as well as handle
that the education and learning system has actually not feelings, evaluated by an efficiency action of emotional
supplied them based on lead their life gladly as well as intelligence (the MSCEIT), and also associated
to form them, efficient people. According to this concept favorably with educator scores of scholastic success
finding out the abilities which are essential to operating and also adjustment for both men and also ladies. The
efficiently in life are more crucial than attaining research exposed that the psychological capacities
academically. A number of the EQ optimists think that are favorably associated amongst the ladies with peer
the students that attain academically have actually relationship elections as well as likewise discovered
not yet created their emotional intelligence and also that EI is favorably connected with instructor rankings
are not most likely able to accomplish their complete of scholastic adjustment amongst children and also peer
ability The students do execute well unless as well as relationship elections amongst students. The example
up until they are participated in creating their feelings, of students was arbitrarily selected. The outcome of the
finding out designs, individuality, as well as inspiration research was that emotional intelligence, self-idea as
concept finding out the abilities which are required to well as the esteem of the students was favorably related
operate properly in life, are more crucial than attaining to their scholastic accomplishment.
academically. A lot of the EQ optimists think that the
researched the connection in between the 5
[7]

students that accomplish academically have actually not

measurements of emotional intelligence i.e., self
yet established their emotional intelligence as well as are
understanding, psychological monitoring, self-
not most likely able to accomplish their complete ability.
motivation, compassion, social abilities and also
scholastic efficiency. The record exposed that there
Review of Literature is substantial connection in between self-awareness,
[5] psychological monitoring as well as compassion with
examined the result of emotional intelligence
scholastic efficiency.
on scholastic efficiency of 246 teenage students. His
evaluation records disclose that the students with high [5]
has actually carried out a research study as well
degree of emotional intelligence do well fairly with that as checked out that just how Emotional intelligence have
said of the students having reduced degree of emotional crucial medical and also restorative ramifications as it is
intelligence. raised from a combinations of research study searchings
for on just how individuals assess, interact and also
[8]
checked out the connection between emotional
utilize feelings.
intelligence as well as scholastic success in non-
typical university student. As the students have has actually mentioned that there hasn’t sufficed
[4]

various cognitive capabilities, the duty of emotional research study to plainly recognize the influence of
intelligence can be much better comprehended in their Emotional intelligence on the scholastic success.
scholastic accomplishment His evaluated that emotional
[8]
intelligence was dramatically relevant with the students performed a study on 500 IX basic students
Grade Point Average, cognitive capabilities as well as of Kannada language to recognize the influence of
age. emotional intelligence on the scholastic
accomplishment.
Emotional Intelligence and Its Origins: The locations Figure 1: 7 Elements to Intelligence
of the rate of interest which have actually been
examined throughout the human background and also
located to be recursive are Human intelligence as well as
a sensible idea. There were numerous different
analyses of these principles. Thinking about the
altering nature of these
2 ideas, the present interpretation of intelligence is a
brainpower (or established of brainpower) that allows
the acknowledgment, finding out memory for, and
also capability to factor concerning a specific type of
details”. There is no person solitary and also unitary
kind of intelligence, yet a collection of them, as well as
component of this knowledge, concentrates on the
means people see feelings as well as just how they
respond to them; this goes to the core rate of interest of
EQ.

In 1920’s the standard idea behind the EQ was

established by Eduard Thorndike while he was
collaborating with social knowledge; as a precursor
to the detailed concept of intelligence. The social
intelligence meaning provided by [6] was as “the capacity
to recognize males and females, young boys as well as
ladies-- to act intelligently in human relationships”.

These were the first actions which led the way for
the development of EQ. Thorndike did not develop any
kind of academic idea of social intelligence; he utilized
this as a picture to expose that the intelligence can be
revealed in various means. The suggestion of numerous
knowledge was additionally established by [10]. from the
instructional viewpoint, he determined 7 elements to
intelligence:
What Is Emotional Intelligence?: Emotional
intelligence is among one of the most extensively
reviewed subjects in an instructional job and also
business psychology. [9] compete that emotional
intelligence is not a solitary quality or capacity instead,
a compound of distinctive feeling thinking capabilities.
Regarding feelings contain acknowledging as well as
translating the definition of numerous moods, along with
their connections to various other sensory experiences.
Comprehending feelings entail an understanding of
exactly how fundamental feelings are mixed to create
complicated feelings. Managing feelings includes
the control of feelings in oneself and also in others.
A person’s emotional intelligence is an indication of
just how she or he regards, comprehends and also
controls feelings. [5]has actually recommended various
perception of intelligence, which he calls effective
intelligence. Effective intelligence entails 3 unique sorts
of brainpower: analytic, innovative and also useful.
Emotional intelligence was specified as the capacity to
view feeling, incorporate feeling to promote the idea,
recognize feelings, as well as to manage feelings to
advertise individual development.

EQ is specified as a collection of expertise showing

the capability one needs to identify his/her behaviors,
state of minds, and also impulses, and also to handle
them finest according to the circumstance. Usually,
“emotional intelligence” is taken into consideration to
entail psychological compassion; interest to, as well as
discrimination of one’s feelings; precise
acknowledgment of one’s very own and also others’
state of minds; state of mind administration or control
over feelings; action with ideal (flexible) feelings as
well as practices in different life circumstances
(particularly to stress and anxiety as well as tight spots);
as well as harmonizing of truthful expression of feelings
versus politeness, factor to consider, and also regard
(i.e., property of great social abilities as well as
interaction abilities)..

Slf-Motivation: Individuals with a high level of

emotional intelligence is normally inspired. They want
to postpone prompt outcomes for long-lasting success.
They’re extremely effective, enjoy an obstacle, as well
as are really efficient in whatever they do.

Self-Awareness: Individuals with high emotional

intelligence are typically extremely independent. They
recognize their feelings, and also due to this, they do not
allow their sensations to rule them. They’re positive-- due
to the fact that they trust their instinct as well as do not of rural and also urban lady’s students was discovered.
allow their feelings to leave control. They’re additionally Rural students were discovered to have obtained even
happy to take a straightforward consider themselves. more psychological security emotional intelligence as
They recognize their toughness, as well as weak points, contrasted to urban woman’s students. A statistically
as well as they, service these locations so they can substantial distinction of taking care of connection
execute far better. Lots of people think that this self- psychological smart of Rural and also urban students
awareness is one of the most vital parts of emotional were located. Rural students were discovered to have
intelligence. actually obtained extra handling relationship emotional
intelligence as contrasted to urban students.
Compassion: This is possibly the second-most essential
aspect of emotional intelligence. Compassion is the Ethical Clearance: Not Required
capability to relate to as well as recognize the desires,
requires, as well as point of views of those around you. Source of Funding: Self
Individuals with compassion are proficient at identifying
the sensations of others, also when those sensations Conflict of Interest: Nil
might not be evident. Because of this, understanding
individuals are normally superb at handling connections, REFERENCES
paying attention, as well as connecting to others. They 1. Xie TW. Using computers in Chinese language
stay clear of stereotyping as well as evaluating as well
teaching. In: Chu M, eds. Mapping the course
swiftly, and also they live their lives in an extremely
of the Chinese Language Field. Kalamazoo,
open, truthful means.
MI: Chinese Language Teacher Association
Social Abilities or taking care of connection: It’s Monograph Series; 1999;3:104-119.
typically very easy to talk with and also like individuals
2. Zhang ZS. Language learning for Chinese-issues
with excellent social abilities, one more indicator of high
and practice. Journal of the Chinese Language
emotional intelligence. Those with solid social abilities
Teachers Association. 1998;33:51-82.
are generally group gamers. As opposed to concentrating
on their very own success initially, they aid others to 3. Yu HJ, Michaels GH. Cyber Chinese: A
create as well as radiate. They can handle conflicts, are multimedia aid for elementary Chinese language
superb communicators, as well as are masters at the instruction: Overview and evaluation. Journal of
structure as well as preserving partnerships. the Chinese Language Teachers Association.
The today research study has actually utilized the 1998;33:39-49.
concept of EI which is based upon the concept of EI 4. Zhang LH. Stepping carefully into designing
as recommended by Goleman. The EI design taken computer-assisted learning activities. Journal
on in this research study contains 10 elements. The 10 of the Chinese Language Teachers
parts that make up EI are: (i) Self- understanding (ii) Association.
Compassion (iii) Self-motivation (iv) Psychological
2004;39:35-48.
security (v) Taking care of relationships (vi) Worth
alignment (vii) Dedication. 5. Xu P, Jen T. Penless Chinese language learning:
A computer-assisted approach. Journal of
Conclusion the Chinese Language Teachers Association.
2005;40:25-42.
It can be evaluated that there is no influence of EI
on the scholastic efficiency given that the EI degrees 6. Tao L, Bond Z. Speech recognition technology
of urban students are high although their Grade Point in the instruction of mandarin Chinese. Journal
Average is much less than the rural students Rural of the Chinese Language Teachers
students were discovered to have actually obtained extra Association.
self- inspiration emotional intelligence as contrasted 2006;41:57-88.
to urban lady’s students. A statistically considerable
distinction of psychological security psychological smart
7. Xie TW. E-generation’s Chinese language
teachers: Meeting the new challenges. Journal
of the Chinese Language Teachers Association.
2001;36:76-80.
8. Ihde WT, Jian M. Language learning and the 12. James W. The principles of psychology, New
on-line environment. Journal of the Chinese York Smith 1890; 2.
Language Teachers Association. 2003;38:25-50.
13. Morgan CT. Introduction to Psychology, Tata
9. Codaty Jyostana. Understanding Emotional McGraw Hill Publications, 2001.
Intelligence. Pustak Mahal, Delhi, 2004.
14. Mundada Khalane. Fundamental of Psychology,
10. Guilford JP. Fundamental statistics in Psychology 1st Ed, Atharv Publication, Jalgaon, 2013.
and Education. New York, McGraw Hill, 1956.
11. Guilford JP. The nature of human intelligence.
New York McGraw Hill, 1966.
DOI Number: 10.5958/0976-5506.2019.01589.4

Caries Risk Profiles of Rural and Urban 12 Year Old School

Children in Mangalore Using the Cariogram

Jyotsna Malhotra1, Ashwini Rao2, Ramya Shenoy3, Mithun Pai BH3

1
Ex-Post Graduate Student, 2Professor, 3Associate Professor, Manipal College of Dental Sciences,
Light
House Hill Road, Mangalore, MAHE Manipal

ABSTRACT
Objectives: This study aimed at determining caries risk profiles of rural and urban 12 years old
school
children in Mangalore using the Cariogram.
Method: A cross-sectional study was conducted on 100, 12 year old school children in Mangalore.
Random sampling technique was employed for sample selection. Data collected from the participants
comprised of demographic details, oral hygiene practices, medical history and a 3-day diet diary. Clinical
examination was done to determine dental caries experience using the WHO Oral Health Assessment
proforma 1997.
Results: In the permanent dentition 60% of the participants had dental caries, whereas 40% of the
participants
were caries-free. Based on the Cariogram scores, students were classified into four groups High risk (0-
40%), Moderate risk (40-60%), low risk (60-80%) and very low risk (80-100%). Mean scores obtained for
each category were 33.75 ± 5.82, 52.44 ± 4.69, 68.11 ± 3.818, 86.03 ± 1.81. None of the participants from
urban area were in high-risk group, whereas 12% of the rural participants were in the high-risk group.
Mean score obtained for urban and rural area were 73.48 ± 15.39 and 58.08 ± 18.94 respectively. The
difference in the mean was statistically significant (p <0.001).
Conclusion: The rural population had a higher risk of developing dental caries as compared to the urban
population.

Keywords: Caries risk assessment, Cariogram, Dental Caries, Risk factors.

Introduction Light House Hill Road, Mangalore, MAHE Manipal

Dental caries is the most prevalent condition in

the world today. Global burden of untreated caries in
permanent teeth in 2010 was estimated to be
affecting
2.4 billion. In children it is the tenth most prevalent
condition, affecting about 621 million children across
the globe. The global burden of caries has remained
unchanged between 1990 to 2010, but tooth loss due to
caries has declined significantly in the past two decades.
The peaks of caries burden are observed at 6 years, 25
years and 70 years1.

Corresponding Author:
Dr. Ashwini Rao
Professor
Manipal College of Dental Sciences,
In India, caries prevalence in children aged 5, 12 and
15 years is reported to be 48.11%, 43.34% and
62.02%
respectively and mean significant caries index score was
3.30, 2.73 and 3.752. Untreated caries, can progress to
severe infection and pain, leading to impaired
performance in schools and decreased productivity at
work3.

Various methods have been devised to predict

risk of development of caries, and one of them is the
Cariogram, developed by Bratthall D4 in 1996, WHO
collaborating centre Malmö University, Sweden. The
process of evaluating the risk using Cariogram is called
Cariography. Cariogram uses the multifactorial cause of
dental caries. It gives the result as “Percent chance to
Avoid Caries” by taking into account the interaction of
diet, bacteria, host factors and the fluoride availability4.

Although caries risk assessment has been done

in different parts of the world, very few of them have
been done in India, with no literature found in this part
335 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 335

of the country. Keeping this in mind, this study was Distribution of the study subjects based on the risk
conceptualised to determine the Caries Risk Profiles categories and caries risk factors revealed that none of
of Rural and Urban 12 Year Old School Children in the participants in the high-risk group had DMFT=0,
Mangalore using the Cariogram. whereas 37 in the very low risk category had no past
caries experience. Eight participants in the high-risk
Materials and Method and moderate risk groups had caries experience ≥ 3
versus zero participants in the low-risk and very low-
This was a cross-sectional descriptive type of study. risk groups. The caries experience increased with the
The present study was conducted among 12 year old likelihood of developing new caries in the near future.
school children in Mangalore. Data collection included
an interview schedule, clinical examination and salivary The Lactobacilli count and the Streptococcus
analysis. Dental caries was assessed using the DMFT mutans count was found to decrease as the chance of
Index5. Children were asked to chew a modeling wax avoiding new caries increased. About half of them had
made into a form of pellet (0.5 x0.5 centimeters) for 3 negligible Lactobacilli count, 25% of them belonged
minutes to obtain stimulated saliva, which was collected to very low risk category, whereas only 3% were from
in a sterile bottle and then subjected to analysis. the high-risk category. Only one from the high-risk
group had Lactobacilli count of over >105 CFU/ml.
The various factors/variables were given a score The Streptococcus mutans count was negligible in
according to a predetermined scale and entered in the one-third of the participants. Of the thirty-three percent
Cariogram computer program4. A trained recorder Streptococcus mutans free, 22% were in the low-risk
accompanied the investigator and helped in recording category versus only one from the high-risk.
the data.
Salivary analysis of the participants revealed High
Results buffering capacity of 31% among participants in the low-
risk group, whereas only 7% had high buffering capacity
A cross-sectional study was conducted on 100, (pH>6.0) in the high-risk group. In the high and
12 year old school children in Mangalore. There moderate- risk category 3 participants each had low
were buffering capacity (pH<4.0). Salivary flow rate obtained
50 participants from urban schools and 50 from rural was found to have no association with the Cariogram
schools. Among the rural participants 58% were males scores.
and 42% were females, whereas in urban population
56% were males and 44% were females. In the Chi-square test was applied to test the association
permanent dentition 60% of the participants had dental between the chance of avoiding new caries and the
caries, whereas 40% of the participants were caries-free. contributing factors. It was found that statistically
The caries prevalence in rural and urban children significant negative association was seen between the
was chance of avoiding new caries and past caries
74% and 46%. The dental caries experience was found experience, Lactobacilli count, Diet frequency,
to be higher in rural population as compared to the Streptococcus mutans count and salivary buffering
urban population and this was found to be statistically capacity. No statistically significant association was
significant (p<0.001). seen between Fluoride programme and amount of saliva
secretion.
Caries risk assessment was done by using the
Cariogram model. Variables involved in the Cariogram Among the 100 students selected, there were 12, 32,
were fed into the software and result was recorded as 18 and 38 in the high risk, medium risk, low risk and
“Chance to avoid new caries”. Based on the scored very low risk categories respectively. Mean score in
obtained from the Cariogram children were categorized each category was calculated to be 33.75 ± 5.82, 52.44 ±
as High risk (0-40%), Medium risk (41-60%), Low risk 4.69,
(61-80%) and very low risk (81-100%). In this study 68.11 ± 3.818 and 86.03 ± 1.81 respectively. Total mean
there were no children with 0-20% chance of avoiding score of the children was found to be 65.78 ± 18.83.
caries, so we combined the groups, very high risk and Based on the area of residence, it was found that in the
high risk, and reported them together as 0-40% chances urban area no participant had high risk of developing
of avoiding caries6.
336 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 336
caries, whereas in the rural area 24% students were
classified as belonging to the high-risk group.
The mean Cariogram score calculated for urban A statistically significant correlation was found
and rural children were 73.48 (15.39) and 58.08 (18.94) between the risk factors and chance of avoiding new
respectively. For all the categories among urban and caries (p<0.001), Lactobacilli count (p=0.017), Diet
rural students mean scores were calculated for the frequency (p<0.001), Streptococcus mutans count
different risk categories. Based on the area of residence (p<0.001), and salivary buffering capacity (p<0.001).
the difference between the means of urban and rural No statistically significant correlation was seen between
areas was found to be statistically significant in low- Fluoride programme and amount of saliva secretion
risk and very low risk categories (p= 0.013 and <0.001 (Table 3).
respectively) (Table 1).
Table 3: Correlation between Cariogram Sector –
Table 1: Cariogram scores of each risk group Chance to avoid new caries and caries related factors

Number Mean ± S.DCariogram

P value
High risk 12 33.75 ± 5.82 score
Decayed missing and filled
Moderate risk 32 52.44 ± 4.69-0.851 <0.001*
teeth (DMFT)
Low risk 18 68.11 ± 3.818
Lactobacilli counts -0.311 0.002*
Very low risk 38 Diet frequency86.03* ± 1.81-0.534 <0.001*
Total 100Streptococcus mutans
65.78* ± 18.83-0.738
counts <0.001*
* Comparison is significant at the 0.05 level Fluoride programme -0.176 0.080
There are five sectors in the Cariogram model. Each Salivary secretion rate -0.025 0.804
is affected by a combination of risk factors. The Salivary buffering capacity -0.314 <0.001*
outcomes of these sectors were separately analyzed for *Correlation is significant at the 0.05 level
both urban and rural study subjects. The means obtained
for Chance of avoiding caries, circumstance,
Discussion
susceptibility, bacteria and diet for rural population
was found to be 58.08 Children of age group 12 years was selected since
± 18.94, 5.08 ± 3.52, 14.80 ± 8.12, 14.54 ± 6.43 it is considered as the global monitoring age for dental
and caries by the WHO5. The dental caries prevalence was
7.60 ± 4.91 respectively. For urban population means found to be 60%, but caries expressed as mean DMFT
obtained for Chance of avoiding caries, circumstance, was relatively low. This is in accordance with the study
susceptibility, bacteria and diet were 73.48 ± 15.39, conducted by Hebbal et al6 and Mascarenhas et al7. In
2.54 ± 2.25, 10.72 ± 5.51. 9.12 ± 5.69 and 4.56 ± 3.45 the present study prevalence of the decayed and missing
respectively. The total means of all the sectors were teeth in urban children was less as compared to those
found to be statistically significant (Table 2). residing in the rural areas, this finding was in accordance
with that reported by John et al8. Of the 100 children
Table 2: The mean Score of the participants based selected only 38% were classified into very low risk
on the five sectors of the Cariogram caries. This could be due to low utilization of dental
services for prevention, unless they are in pain in India
Total as reported by Harikiran et al9 and Poudyal et al10 .The
Mean S.D study findings are similar to the findings reported by
Chance to avoid caries 65.78* 18.83 Hänsel Petersson et al11, where about 40% belonged to
Circumstance 3.81* 3.20 the very low risk category. The risk of the students in
the present study was in contrast to the results reported
Susceptibility 12.76* 7.19
by Campus et al. 12 and Hebbal et al6 where about 20%
Bacteria 11.83* 6.63 and 21% of the students were in the very high-risk
Diet is significant at6.08*
*Comparison the 0.05 level 4.49 group respectively. The caries risk factors included in the
evaluation of risk prediction using the Cariogram model importance. In addition to that, co-operation from the
patients in high caries risk group had high scores in past school authorities could help in developing school oral
caries experience, Lactobacilli count, Streptococcus health programmes to aid in imparting oral health
mutans count and diet frequency. Sonbul et al13 and education to all the children from an early age. Thus, to
Campus et al12 reported similar results in addition to reduce the caries burden of the population, emphasis
other factors like use of fluoride and plaque amounts. should be laid on the prevention of the disease. Spreading
awareness about oral hygiene practices, dietary
Mean DMFT increased in the groups as the chances
modifications and importance of maintaining oral health
of avoiding new carious lesion reduced (from lowest to
among the general population and the children will go a
the highest groups). This finding was similar to those
long way in preventing oral diseases and promoting oral
reported by Tayanin et al14, and Campus et al12, who
health.
reported increment in DMFT/dmft and DMFS/dmfs with
decrease in the chances of avoidance of new caries. Past Source of Funding: Self
caries experience is considered to be the most reliable
predictor for assessing the caries risk than other risk Ethical Clearance: Permission to conduct the study
factors. Studies have been conducted which confirmed was obtained from the Institutional Ethics Committee of
the strong prognostic role of past caries experience in MCODS, Mangalore.
predicting dental caries 15,16,17, but the study conducted by
Conflict of Interest: None
Hausen et al18 concluded that providing any additional
preventive measure to control risk factors does not affect
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DOI Number: 10.5958/0976-5506.2019.01590.0

Role of Trust and Privacy Concerns towards Usage of

E-Health Services—An Extension of Expectation-Confirmation
Model

K Anil Kumar1, Subhashree Natarajan2

1
Teaching-Cum-Research Assistant, 2Professor and Dean, VIT Business School, Vellore Institute
of
Technology

ABSTRACT
Electronic health services is extensively employed to build an online platform for healthcare providers and
patients. However, there are few studies that have investigated the intention behind why e-Health services
are rejected by some of the end-users after their initial experience. There exists a considerable gap between
the usage of e-Health services and our understanding of these technologies. Therefore, this study was
carried out on the aim to better understand the factors leading hospital consumers’ continued usage of e-
Health services based on expectation-confirmation model (ECM). To explore the process of continuance
usage intention of e-Health services, the study has integrated ECM model with technology acceptance
model and two post adoption expectation beliefs (i.e., perceived privacy and security, and perceived trust).
With 253 e-Health services users’ responses, the proposed research model was empirically tested within the
context of e-Health services by applying partial least squares (PLS) method. The main finding from the
path analysis indicates that along with perceptual (confirmation, perceived ease-of-use, perceived
usefulness), and emotional factor (satisfaction), post adoption expectation beliefs (perceived trust,
perceived privacy and security) – also shown a significant association towards continuance intention of e-
Health services. The study concludes by discussing theoretical and practical implications, limitations and
future scope.

Keywords: expectation-confirmation model, technology acceptance model, perceived trust, perceived

privacy and
security.

Introduction applications accounts in the entire range of information

like hospital and employees information, billing and
E-Health refers to application of software that
payment information, and patient’s medical records. In
includes the process, tools, and communication systems
today’s viewpoint of e-Health, it also includes the use of
to support the practices of electronic healthcare. E-
internet for storing, modifying, and accessing the health-
Health services helps in transmission and administration
related information. Nevertheless, the term e-Health is
of information in healthcare and as an outcome, assist in
much broader, that covers digitalization of several tasks
enhancement of medical practitioner’s performance and
and processes of healthcare from basic to advanced
patients’ health. Varshney15 defines electronic Health
level of services that results in innovative terms such as
as an application of ICT across the various activities
e-appointments, e-records, e-supply, e-payments, and
involved in practice and delivery of healthcare.
e-billing. Though the application of ICT are numerous in
These
healthcare sector, this research precisely refers to basic
e-Health services provided by the private hospitals like
Corresponding Author: e-appointment, e-billing, and e-payments as they are
Subhashree Natarajan feasible and not much complicated to the end-users (i.e.,
Professor and Dean, VIT Business School, patients). These basic services helps in saving the end-
Vellore Institute of Technology users time and offers a rapid communication between
patients and healthcare professionals4.
340 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 340

Prior researches have reported that patients’ use expectation belief 14. In most cases, incorporating the
these e-Health services barely for a short span of time other beliefs with the existing factor – PU is
as it is a contemporary experience to them and have less predominately based on the nature of the specified
knowledge in it11, which clearly highlights the lesser technology in specified context to enhance the
understanding of post-adoption behaviours of end- explanatory power of the model. With the
users by the institutions. This recommends a demand
background of this tradition, this study focus on
to delve intensively into post-adoption behaviour (i.e.,
integrating perceived privacy and security as a
continuance usage intention - CUI) of e-Health services
significant post adoption expectation belief to
usage. With a focus of Indian healthcare customers, this
understand the CUI of e-Health services13. Prior studies
study predicts how a comprehensive set of factors may
influence the continuance intention of e-Health services. have included PPS as an antecedents to study the post
adoption behaviour of consumers in adoption of
To identify the essential factors, this study further various e-services likes e-banking and e-government that
integrates ECM with TAM (Technology Acceptance demonstrates the linkage between satisfaction, PPS,
Model) and also incorporates perceived trust (PT) and and CUI2. Similarly, this study also considers perceived
perceived privacy and security (PPS) to hypothesize trust that has an exceptional influence on CUI linked
a new model. The reason behind the integration is as through SAT. Although the relationship between PT,
follows- First, though ECM was proved to be the robust PPS, and usage intention is not precisely been modelled
model to study the continuance intention of information
in information technology, the association is
system by several studies4, it employs only three
explicitly inferred in certain studies. Therefore, this
predictors, specifically, confirmation (CNF), perceived
study anticipates that it will be significant to examine the
usefulness (PU), and satisfaction (SAT) to measure
role of these two additional variables to predict the post
continuance usage intention (CUI). Nevertheless, the
users’ behavioural intention towards usage of any adoption behaviour of e-Health services.
technology may be influenced by other factors. Second,
TAM offers a significant factor perceived ease-of-use Research framework and Hypotheses
(PEOU) to measure the usage intention that affects
perceived usefulness, and it act as a precedent factor In conceptualizing a continuance model for e-Health
for PU for ECM. And finally, adding PT and PPS to the services, this study has integrated ECM with TAM
integrated model allows to capture the possible element factor
of barriers to the e-Health services CUI. – PEOU, and two external variables - PT and PPS to
predict SAT and CUI. As explained in Fig. I, the
The existent literature on the viewpoint of ECM has research framework has extended ECM viewpoint by
mostly concentrated on PU as the only continuance including the influence of perceptual factor and two post
usage adoption expectation beliefs in the background of
electronic Health services.

Fig. I: Proposed Model

Hypotheses based on base ECM: The original ECM H2d: PEOU has a significant association with CUI
that was proposed by Bhattacherjee3 majorly focused on of
the factor PU of any technology. The concept of ECM e-Health services
states that when the initial expectation of individuals get
confirmed with the usage of any technology, then they
perceive the technology to be useful for performing any
specified task11. That is, when the technology allows the
user to accomplish the chosen goal in the anticipated
way, then their experience towards perceived usefulness
is increased. Thus with the base of original ECM, the
following hypotheses were proposed:

H1a: CNF of expectation has a significant

association
with PU of e-Health services

H1b: CNF of expectation has a significant

association
with SAT of e-Health services

H1c: PU has a significant association with SAT of

e-Health services

H1d: PU has a significant association with CUI of

e-Health services

H1e: SAT has a significant association with CUI of

e-Health services

Integrating ECM and TAM: The base TAM model

highlighted the positive association between PU and
PEOU on attitude towards technology and finally
measuring the behavioural intention to use it. According
to Akter1, satisfaction is a positive and pleasurable state
of attitude and emotion. And therefore it is reasonable
to hypothesize that perceptual factors like PEOU and
PU has a significant effect on individuals’ satisfaction
with usage of any technology. Prior studies have also
highlighted the significant association among PEOU
and PU towards SAT and behavioural intention to use
e-services3,12.. Thus the subsequent hypotheses were
proposed:

H2a: CNF of expectation has a significant

association
with PEOU of e-Health services

H2b: PEOU has a significant association with PU

of
e-Health services

H2c: PEOU has a significant association with SAT

of
e-Health services
Perceived Trust and Perceived Privacy and Security:
The role of ‘trust’ and ‘privacy and security’ in the
context of electronic services are robust. The prior
study has shown that CNF of expectation has a positive
influence with the execution of certain guidelines guided
by trusting beliefs6,14. Further, extant literature has
proven that degree of users’ trust has a positive effect
towards degree of CUI. Earlier studies have claimed
that, in healthcare, higher privacy and security drives
the increased satisfaction level of patients’ and as a
outcome11, results in repeated usage of electronic Health
services8. Thus the following hypotheses are posited:

H3a: PPS has a significant association with PT of

e-Health services

H3b: PPS has a significant association with SAT of

e-Health services

H3c: PT has a significant association with SAT of

e-Health services

H3d: PT has a significant association with CUI of

e-Health services

H3e: PPS has a significant association with CUI of

e-Health services

Data Collection
As the study focuses on the customer perspective
of the hospitals, the sample unit opted for this study are
patients’ and care-givers, who are considered as the
major customers of hospitals. The data was collected
from the multi-speciality hospitals those are providing
basic e-Health services to its customers. The
geographical location chosen for data collection of the
study is Chennai. The sampling method used for this
study is purposive sampling method, as it is a
challenging task to precisely estimate the population
size of patients’ acquiring the treatment or the care-
givers who are using the basic e-Health services for the
sake of patients’ in India. The final sample size of
the study resulted in
253. The data was collected through the well-structured
closed ended questionnaire.

Data Analysis and Results

The research model was accomplished through two
steps: measurement model and structural model. The
outer model was executed to establish the reliability and
validity, whereas, inner model was carried out to test the
study hypotheses.
Table I: Confirmatory factor analysis results

Construct Item Standard loading* AVE CR Cronbach’s α

PU1 .794
PU2 .859
Perceived usefulness 0.783 0.904 0.918
PU3 .847
PU4 .849
CON1 .890
CON2 .899
Confirmation 0.800 0.851 0.929
CON3 .920
CON4 .880
PEOU1 .824
Perceived ease-of- PEOU2 .848
0.768 0.912 0.889
use PEOU3 .847
PEOU4 .832
PPS1 .867
PPS2 .881
Perceived privacy PPS3 .900
0.841 0.935 0.911
and security PPS4 .863
PPS5 .799
PPS6 .782
TR1 .832
TR2 .933
Trust 0.827 0.924 0.896
TR3 .822
TR4 .789
STF1 .884
Satisfaction STF2 .896 0.790 0.938 0.915
STF3 .879
CUI1 .897
Continuance usage CUI2 .884
0.774 0.912 0.893
intention CUI3 .853
CUI4 .819

Assessment of Measurement Model: The research model was established in two phases. First, the outer model
(i.e., measurement model) was analysed to validate the properties of measurement scale, for which confirmatory
factor analysis was estimated. This helps in accessing the reliability, discriminant validity, and convergent validity
of the scale (Table-I). Secondly, structural model was analysed to validate the path relationship. According to Hair
et al, the cut off values for composite reliability (CR) and average variance extracted (AVE) should be equal to or
exceed 0.80 and 0.50 respectively. Here, the minimum value of CR is 0.851 for CNF and highest value is 0.938 for
SAT; and for AVE, minimum value is 0.768 for PEOU and highest value is 0.841 for PPS which signifies the
adequacy of criteria. Further, the value of Cronbach’s alpha lies between the range 0.889 and 0.929, which
satisfies the recommended threshold value of 0.7.
Fig. II: Inner Model results

Assessment of Structural Model: The results of inner model (Fig. II) are summarized in Table- II, which shows
the indirect, direct and total effect of the variables. The proposed model is claimed to have the strong prediction
power, where R2 of all the endogenous variables are higher than 0.60 along with CUI (0.709). The outcome of the
model shows that all the proposed hypotheses were accepted including the base ECM hypotheses (H1a – H1e)
which is considered valid in healthcare context. For example, the association between CNF towards SAT was found
to be strongest (t-value-16.814). Further the extended model hypotheses (H2a - H2d and H3a – H3e) has also shown
significant. The variables like trust (t-value-8.698), PPS (t-value-4.503), and PEOU (t-value-4.277) are positively
associated towards satisfaction. Also the path from PT (t-value-3.015), PPS (t-value-4.721), and PEOU (t-
value:
3.541) are significantly associated towards CUI.

Table II: Direct, Indirect and Total Effect

PPS Trust CNF PU PEOU STF
PPS DE
IE
TE
Trust DE 0.565
IE 0.137
TE 0.702
CNF DE
IE
TE
PU DE 0.543 0.707
IE 0.196
TE 0.739 0.707
PEOU DE 0.551
IE
TE 0.551
STF DE 0.319 0.434 0.790 0.373 0.226
Conted…
IE 0.182 0.146 0.188 0.086
TE 0.501 0.580 0.978 0.459 0.226
CUI DE 0.259 0.171 0.494 0.198 0.143
IE 0.674 0.198 0.063
TE 0.259 0.171 0.674 0.692 0.261 0.143
Discussion in order to increase the trusting belief and attitude (i.e.,
CUI). Further, loss of privacy and security results in loss
The main aim of this study is to examine the post-
of trust10. If the service provider focus on improving the
adoption behaviour of users’ using the e-Health services.
security concerns, then it directly results in increasing
In an attempt to this, the study has developed a research
trust which finally influence SAT and CUI8.
model in the context of healthcare by integrating ECM,
which is theoretically reliant on ECT with technology Limitations and Future Scope: First, this research
acceptance model. Further the study has incorporated the was carried out within the particular field of e-Health
constructs like PT and PPS to the research model. The services in a single country. As an outcome,
main findings of the path analysis has supported all the applicability of the findings more broadly remains
proposed hypotheses. Along with the theoretical model uncertain. It is vital for practitioners and researchers to
factors, the additional variables like PT and PPS has take a more holistic, learning oriented method to
shown significant association towards SAT and CUI, and determine the performance of such e-Health services.
also shown an important role in enhancing the predictive Second, follow-up research on longitudinal data is
power of the research model. Further, conceptualising required for this study. As the cross-sectional data does
and validating their impact on usage intention (via SAT) not permit for the analysis of post-acceptance model’s
is a significant contribution of this study. Altogether, this predictive power in gaining knowledge of continuance
study contributes to the information technology CUI intention.
literature by integrating TAM with ECM and confirming
the effect of PT and PPS into the perspective of ECM In other words, to examine the fundamental effect
to explain the end-users’ post-adoption behaviour in of perceptual factors on actual behaviours, it is crucial
healthcare context. to conduct longitudinal study as the exogenous variable
must precede endogenous variable in order to deliberate
In terms of practice, the constructs PEOU and PU as having a causal influence9. Specifically, for better
have statistically shown positive association towards understanding, it is recommended for future study to
SAT and CUI of e-Health services. But PU has shown conduct a panel study by gathering longitudinal data
greater effect than PEOU. This signifies that PU has a from a specific set of e-Health service users’ at multiple
crucial part in defining users’ attitude towards any new temporal points. Finally, the study believes that along
technology. Though usefulness have a greater influence, with TAM and ECM factors, there exists a role of other
PEOU also determines the users’ emotional state. external variables. For instance, the study of Davis 5
This finding states that future research can emphasize emphasize that the role of social influence significantly
on the ways in which the effects of PEOU and PU on influences the perceptual factors like PEOU and PU.
emotional states are contextually bounded in healthcare Henceforth, future study can investigate the role of
context11. However, service providers’ needs to focus on social influence towards continuance intention of
making the e-Health services easier and useful. Though electronic Health services.
e-Health includes several services, it has become clear
that an efficient and simple operating system is one of Ethical Clearance: Ethical approval was taken from the
the major factor that determines the marketability of respective hospital authorities and from Vellore institute
any e-Health services5. Perceived trust is an important of technology.
element in e-services exchange, as the lack of proper
Conflict of Interest: The authors declared no potential
rules and regulations in electronic services are not
conflicts of interests with respect to the research,
immediately verifiable7. Therefore it is essential for the
authorship, and/or publication of this article.
service providers to improve the overall trusting beliefs
Source of Funding: None
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2. Appari A, Johnson ME. Information security and 10. Lee MC. Explaining and predicting users’
privacy in healthcare: current state of research. continuance intention toward e-learning: An
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3. Bhattacherjee A. Understanding information 11. Martínez-Caro E, Cegarra-Navarro JG, Solano-
systems continuance: an expectation-confirmation Lorente M. Understanding patient e-loyalty
model. MIS quarterly. 2001 Sep 1:351-70. toward online health care services. Health Care
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continued use of health apps. International journal 12. Morgan RM, Hunt SD. The commitment-trust
of medical informatics. 2016 Mar 1;87:75-83. theory of relationship marketing. Journal of
marketing. 1994 Jul;58(3):20-38.
5. Davis FD. Perceived usefulness, perceived
ease of use, and user acceptance of information 13. Mou J, Shin DH, Cohen JF. Trust and risk in
technology. MIS quarterly. 1989 Sep 1:319-40. consumer acceptance of e-services. Electronic
Commerce Research. 2017 Jun 1;17(2):255-88.
6. Dimitrov DV. Medical internet of things and
big data in healthcare. Healthcare informatics 14. Oliveira T, Alhinho M, Rita P, Dhillon G.
research. 2016 Jul 1;22(3):156-63. Modelling and testing consumer trust dimensions
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7. Hoehle H, Huff S, Goode S. The role of continuous
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continuance usage intention in health care
DOI Number: 10.5958/0976-5506.2019.01591.2

Risk Factors Associated with Onset of Neck Pain: A Review

Neha Gupta1, Aparna Sarkar2, Deepak Kumar3

1
Assistant Professor, 2Professor, Amity Institute of Physiotherapy, Noida; 3Head of Department,
Capri
Institute of Manual Therapy, New Delhi

ABSTRACT
Objectives: The current review intended to summarize the risk factors responsible for onset of neck pain.
Method: An electronic and hand search along with cross referencing was done on five online databases
(Cochrane Library, PEDro, Scopus, PubMed (Medline) and Google Scholar) using the following key words,
“neck pain”, “nonspecific neck pain”, “prevalence of neck pain” and “risk factors associated with neck pain”.
Results: Out of 715 papers identified 77 full text papers were reviewed. 12 studies meeting the inclusion
criteria were included and were scored for methodological quality (MQ) on the New Castle Ottawa Scale
modified for cross-sectional studies. Conclusion the identified risk factors for onset of neck pain include
being of female gender, poor working conditions, presence of stress and depression, work overload both for
students and professionals.

Keywords: neck pain, risk factors, prevalence, musculoskeletal

disorders.
Introduction use of computers, mobile phones, internet for both work
and recreation is making our life more convenient but
Neck pain is influencing 14-71% of adults and
at the same time are jeopardizing the musculoskeletal
eventually sooner or later 19-37% of patients will
integrity11,12. Further the increasing stress levels at the
develop a chronic neck pain 1,2. It is a commonly reported
work place are exposing individuals to the development
health hazard3 and is seen in different occupations, in
of neck pain9.
various countries4,5, becoming an economic burden for a
country’s urban population responsible for non- The current review tries to encapsulate the risk
attendance from school, college and work6,7. Neck pain factors identified by recent studies, responsible for onset
is encountered by all age groups including children, of neck pain. This review can be useful to healthcare
adolescents, adults and the geriatric population, also its providers, researchers, ergonomists and employers
incidence and prevalence is amplifying every year. to design interventions reducing the incidence and
Numerous studies conducted over the years have prevalence of neck pain.
identified the exposure variables in different population
subgroups and occupations3,8,9,10. But still with the
Methodology
changing lifestyle and work habits new studies are
required to identify the modernistic up to date The study is approved by the ethical committee of
associations with the risk factors. The augmenting use Amity University. To get a thorough search we followed
of innovative technology which includes the multiplying the PRISMA guideline (Fig 1).

Search Strategy: An electronic and hand search along

Corresponding Author: with cross referencing was done on five online databases
Neha Gupta (Cochrane Library, PEDro, Scopus, PubMed (Medline)
Assistant Professor and Google Scholar) using the following key words,
Amity Institute of Physiotherapy, Amity University “neck pain”, “nonspecific neck pain”, “prevalence of
Noida, Uttar Pradesh-201313 neck pain” and “risk factors associated with neck pain”.
Phone: +919810280410 The period of the search was 1970 to 2018.
Email: [email protected]
347 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 347

Fig. 1: The Prisma Flow Chart for Selection of Studies

Study Selection: After a meticulous screening of the z The study must be a full-length peer reviewed
titles picked by the search strategy, all the papers related report published in English language.
to neck pain and non-specific neck pain were listed by
the first reviewer. Next the abstracts of the articles Quality Assessment Scoring: The selected papers
having the potential to be included in the study were were scored for methodological quality by the Modified
identified and read by two individual reviewers. Finally, Newcastle Ottawa scale by two independent reviewers.
if the abstract connoted that the paper could provide The Newcastle-Ottawa scale consisted of three sections
relevant data regarding the risk factors for onset of namely selection, where a study can score a maximum
neck pain, the full text of screened articles were of 5 stars next comparability where a study can score a
diligently read by both the reviewers individually to be maximum of 2 stars and finally outcome where a study
assessed for the inclusion criteria. In case of can score a maximum of 3 stars. If the scores of the two
disagreement, a meeting was held and consensus was reviewers did not meet for an item, then consensus was
obtained for the same. obtained after a thorough discussion.

A study had to meet the following criteria, for it to Results

be eligible to be included in the current review.
Out of 958 studies identified 12 studies 13,14,15,16,17,18
z The study sample consisting of general population
were included in the current review (Fig1).
,19,20,21,22,23,23
and not patients complaining of neck pain.
z The prime outcome variable was neck pain Methodological Quality: The percentage of agreement
symptoms between the two independent reviewers was 89.9%.
Most of the studies lost a star in the sample size
z Studies must have listed the risk factors for neck category, as the formula or the methodology for the
pain
number of responses was not mentioned. Out of 12 only
z The neck pain examination was distinctly separate one study scored 9 stars19.
from other musculoskeletal disorders.
The Annual prevalence was evaluated in 8 in their studies involvement in regular physical activity
studies
13,15,16,18,19,20,21,23
. The prevalence percentages ranged from
20.3% to 66.7%.

Discussion

The prevalence for neck pain were found to be

inconsistent for different countries. The reason for this
could be various like disparity in the study methodology,
definition of cervical and neck pain15,16. Population
differences like socioeconomic status including the
family income and education of the people, work
culture, practices and lifestyle, human health
cognizance, health care standards, exposure time
factor13,15,16.

All the studies included in the current review have

collected the data by self-report method via filling of
questionnaires. For this review the exposure variables
were broadly divided into three categories. First the
personal second work related/ergonomic and third
psychosocial factors.

Personal: Being of female gender was identified as a

risk factor by 913,14,17,18,19, 20,21,22,23 out of 12 studies
included in the current review. A possible
rationalization of the same could be that females are
more exposed to home care tasks18, child and elderly
care at home which could be more taxing on the neck
musculature. It has been pointed that females have
comparatively less muscle mass and they should engage
in more physical activity to increase the muscle mass
for prevention and treatment of neck pain14,25,26.
Trogen27 in his study reported that pain threshold
increased with muscle strength27,18 and Chiu28
demonstrated that isometric strength was more in men
than women28,18. In a study17 it was speculated that
reasons for higher prevalence of neck pain in girls could
be that they have a lesser pain threshold than boys,
hormonal changes during puberty, greater tendency for
stress, heritability of neck pain is more in girls17,18.

Four studies reported age to be significantly

associated with neck pain13,20,21,23. The possible
explanation of which could be degenerative changes in
the in the ageing musculoskeletal system13,18. Cagnie20
demonstrated that the neck pain risk intensified till the
age of 50 but diminished thereafter. One explanation
given for this was that after the age of fifty other chronic
diseases were more prominent20.

As accounted by Ehsani13 and Cagnie20 and Chiu21

and sports was an effective deterrent strategy for neck
pain, which was contrary to the studies by De Vitta16,
Shan17 and Diepenmaat22. Shan17 in his study explained
that it was difficult to quantify the effect of short
duration exercises and long duration exercises are more
associated with injuries, he suggested that involvement
in regular physical activity predisposes participants
to injuries and muscle soreness and later thus more
neck pain17. One explanation given for the disparity in
findings could be differences in objective definition of
the physical activity22.

Genebra15 in his study has demonstrated that being

separated or widowed was related with neck pain. A
probable explanation could be that they may be more
exposed to house hold and professional work and have
less social support in the absence of partner 15. Inferior
grade education and income may deprive people from
quality health facilities and prevention strategies. Also,
these people are typically more engaged physically
demanding tasks exposing them to a greater risk of
musculoskeletal system injuries15.

Work Related and Ergonomics: Ehsani13 reported

in his study that teachers with a longer duration of
employment had a higher risk of developing neck pain.
Dry air, temperature fluctuations and thermal discomfort
were also significantly associated with neck pain20.
Deficiency of personnel was another factor associated
with neck pain20. Poor working conditions were
reported by 8 studies13,15,18,19,20,21,23,24. Research proves
that maintenance of prolonged sitting with continuous
tiresome neck postures while using computers,
correction of examination papers and leaning activities
were related with neck pain13,15,18. A potential
justification could be an increase in neck extensor
muscles and sternocleidomastoid muscles activity,
simultaneously intensifying the load on the intervertebral
disc, neck ligaments joint capsules etc leading to
inflammation and pain in the cervical spine
structures15,16. Neck holding in forward flexed position
and working in consistent positions for elongated hours
is significantly associated with neck pain as was doing
the same motions every minute20. When distal upper
extremity is at work like at the keyboard, mouse etc.
the proximal musculature of neck and shoulders
should perform as stabilizers, this activity is
heightened when neck movements like rotation and
flexion of neck is also added20.

However, it is denoted that compared to laptop

users, desktop users presented with significantly less
neck pain17. For which the authors theorised that a more postures may be due to poor ergonomically designed
adjustable positioning of the monitor and keyboard workstations or work demands as in case of nursery
separately gave a more congenial posture and thus teachers, existence of stress and depression, work
reduced the occurrence of neck pain17. Variation in overload both for students and professionals. For
computer usage could also explain the differences in the professionals it could be due to shortage of personnel at
observations such as adolescents used computers more work place along with poor social and colleague
for entertainment rather than work and they experienced support, for students it could academic pressure of
more of a discomfort than pain, also if they had pain clearing college entrance exams, as risk factors for
they restricted the computer use as probably the pupils increasing prevalence of neck pain.
were aware that excessive computer usage could
aggravate their problem22. But the fact that self-assessed Conclusion
computer usage can be inaccurate at times cannot
neglected. Maximum number of studies identified being
of female gender, poor working conditions such as
Yeun14 has postulated that neck pain is significantly
demands for awkward and prolong exhausting postures,
associated with mobile phone usage hours. The static
presence of stress and depression, work overload both
neck positions maintained during mobile phone use may
for students and professionals, as risk factors for
lead to muscle soreness18.
increasing prevalence of neck pain.
In an interesting finding it was shown that people
Conflict of Interest: Nil
using mobile phones had comparatively less neck pain
than those using fixed land lines as mobile phones Source of Funding: The study was funded and
allowed more adjustable positioning of neck and there supported
is no need to stand in fixed positions which might have by the authors.
led to more neck pain17. Adolescents may have different
mobile phone using habits than the traditional users
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tiring
level of job satisfaction had a higher risk of developing
neck pain13. Also neck pain was high in those
participants who perceived their health as poor14.

Stress, depression, mental tiredness and anxiety

were other factors found to be associated with neck
pain14,17,20,22,23. Shan17 showed in his study that students
contended with their everyday learning had less neck
pain. Poor social and colleague support were other
psychosocial factors found to be associated with neck
pain.

Findings of our review support the earlier

findings
3. Hogg-Johnson S, Van Der Velde G, Carroll
LJ, Holm LW, Cassidy JD, Guzman J, Côté P,
Haldeman S, Ammendolia C, Carragee E, Hurwitz
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DOI Number: 10.5958/0976-5506.2019.01592.4

Prediction of COPD Using CT Measurements of Pulmonary

Artery and Aortic Diameter

Priyanka1, Abhijith A2, Adarsh Veer Sisoudiya2, Saikiran Pendem3

1
Assistant Professor, MSc. Medical Imaging Technology, 2BSc. Medical Imaging Technology, 3Assistant
Professor, Department of Medical Imaging Technology, Manipal College of Health Professions,
Manipal Academy of Higher Education, Manipal

ABSTRACT
Introduction: Chronic obstructive pulmonary disease (COPD) is group of progressive lung disease which
commonly includes emphysema and chronic bronchitis. Among non-communicable disease, COPD is
estimated to be second largest cause of death in India. Computed Tomography (CT) of chest and
measurements of arteries could be simple and effective modality for diagnostic evaluation of COPD.
Aim: To determine whether CT measurements such as Pulmonary artery and aortic artery
diameters are
useful in predicting COPD.
Materials and Method: A total of 291 patients was included in this retrospective study who had underwent
CT thorax from April 2016 to April 2018. 194 patients with COPD were taken as cases and 97 patients
without any history of COPD were taken as controls. Diameters such as Main pulmonary artery (MPA), right
pulmonary artery (RPA), left pulmonary artery (LPA), ascending aorta (AAo) and descending aorta (DAo)
was measured on an axial CT thorax image. Ratios of MPA/AAo and MPA/DAo were also calculated. Mann
Whitney U test was used to compare CT measurements between two groups. Receiver operating
characteristic (ROC) curve was used to find sensitivity and specificity of CT measurements in predicting
COPD.
Results: The sensitivity and specificity for MPA, RPA, LPA, AAo, DAo, MPA/AAo and
MPA/DAo was
77.3% & 83%, 74.8% & 79.5%, 71.8 & 78.8, 56.7% & 42.6%, 30.1 & 60.3, 17.3% & 33.8%,
18.9% &
33.8% respectively. There was significant difference in diameters such as MPA, RPA, LPA, AAo and
DAo among two groups (p value <0.001). Whereas no significant difference was found in MPA/AAo and
MPA/ DAo ratios between two groups (p value >0.001).
Conclusion: In present study, we found significant increase in MPA, RPA and LPA diameters in COPD
patients compared to controls. Henceforth, our study concludes that MPA, RPA and LPA diameters could
be useful as reliable indicators in predicting COPD.

Keywords: Computed Tomography (CT), Chronic Obstructive Pulmonary Disease (COPD), Main
Pulmonary
Artery diameter, Right Pulmonary Artery Diameter, Left Pulmonary Artery Diameter, Aortic
Diameter

Introduction
Corresponding Author: Manipal Academy of Higher Education, Manipal–
Dr Saikiran P 576104, Karnataka, India
Assistant Professor, Email: [email protected]
Department of Medical Imaging Technology,
Manipal College of Health Professions,
COPD is characterized by chronic
obstruction of lung airflow that interferes
with normal breathing and not fully
reversible 1. COPD is leading cause of
morbidity and mortality worldwide. It is
estimated to be second largest cause of
death in India and fifth leading cause of
deaths in worldwide 2, 3. Patients with higher
smoking index and exposure to biomass
fuels are found to have more likelihood of
developing COPD 4.
353 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 353

COPD includes chronic bronchitis and emphysema measured at the level of pulmonary artery bifurcation
5
. Chest computed tomography (CT) is widely (Fig. 1). The left pulmonary artery (LPA) diameters was
performed in patients with respiratory symptoms measured at the widest part after main pulmonary artery
because of its simplicity and accessibility, although bifurcation (Fig. 2). All the diameters were measured
radiation exposure is a concern. In addition, Chest CT is by using measuring tools in DICOM Imaging software
a useful tool for thoracic vascular assessment. It could of Mediff technology and were noted in millimeter
detect changes of small vessels, enlargements of the (mm). The ratio of main pulmonary artery/ascending
vessel and these anomalies are important for clinical aorta and main pulmonary artery/descending aorta was
implications6. The Mean diameter of Pulmonary also calculated. The measurements were taken by two
Artery and Ascending Aorta ratio measured using CT readers who were blinded to the diagnosis and measured
was found to be one. However, the ratio in some COPD at different time periods. The inter and intra observer
patients was not greater than one. Fewer studies have variability was calculated.
evaluated the role of measurements such as pulmonary
diameters, aortic diameters and its ratios measured
using CT to predict the COPD. Hence, study was
aimed to find sensitivity and specificity of pulmonary
artery diameters, aortic diameter and its ratio’s in
predicting COPD.

Materials and Method

This was a retrospective study conducted in

Department of Radio diagnosis and Imaging on subjects
who had undergone CT chest from April 2016 to
April
2018. The study approval was obtained from
Institutional Research Committee and Institutional
Ethics Committee (IEC No. - 133/2018). A total of 291
patients with age ranging from 18- 80 years was
included in the study. Fig. 1: Axial CT Thorax image showing
measurement of main pulmonary artery (MPA),
194 patients (120 males and 74 females) with history of
right pulmonary artery (RPA), ascending aorta
COPD were selected as cases and 97 patients (58 males,
(AAo) and descending aorta (DAo)
39 males) without any history of COPD were selected as
controls. Patients with congenital heart disease, valvular
heart disease, aortic aneurysm, pulmonary arterial
hypertension were excluded from the study.

The CT Chest was performed by using Philips 64

slice Brilliance CT scanner with the routine protocol.
Patients were positioned on the CT couch in supine
position, with the area coverage from the apex of the
lung to domes of the diaphragm. The scanning protocol
was the following: collimation of 64×0.625, rotation
time 0.75 seconds, FOV 350 mm, tube voltage of 120
kVp, tube current of 250 mAs, pitch of 1.078, scan time
4.9 seconds, slice thickness of 5 mm, slice increment of
5 mm, a filter of sharp C and resolution standard. The
scan of the required area of interest was performed on
Fig. 2: Axial CT thorax image showing measurement
the acquired scannogram. The images were reformatted of left pulmonary artery (LPA) diameter
in to axial, coronal and sagittal planes and was sent to
PACS. The main pulmonary artery, right pulmonary
artery, ascending aorta and descending aorta was
Data Analysis groups. Intra observer and Inter observer variability for
measurements was using students t-test and kappa value
Statistical analysis was performed using the
Statistical Package for the Social Sciences version Findings: A total of 291 patients were included in this
(SPSS version 22.0). Data were presented by mean ± study which includes 194 cases and 97 controls. The
standard deviation. ROC curve was used to find descriptive statistics for the measured diameters were
sensitivity and specificity of pulmonary artery, aortic reported, which shows the mean and standard deviation
diameters and its ratio in predicting COPD. Mann of both groups (Table 1).
Whitney U test was used to compare diameters and
its ratio between two

Table 1: Mean and standard deviation of the pulmonary artery, aortic diameter and its ratio for COPD
and controls

Diameters (mm) COPD (n=197) Control (n= 94) p value

MPA 26.8 ± 0.47 24.0 ± 0.29 < 0.001
RPA 22.5 ± 0.36 19.7 ± 0.31 < 0.001
LPA 21.4 ± 0.35 19.6 ± 0.27 < 0.001
AAo 32.3 ± 0.41 30.1 ± 0.41 < 0.001
Dao 24.8 ± 0.33 23.6 ± 0.32 0.006
MPA/AAo 0.8387 ± 0.16 0.8080 ± 0.11 0.371
MPA/Dao 1.0961 ± 0.22 1.0310 ± 0.15 0.062

MPA – Main Pulmoary Artery,RPA - Right Pulmonry Artery, LPA – Left Pulmonary Artery, AAo –
Ascending Aorta, DAo – Descending Aorta, COPD – Chronic Obstructive Pulmonary Disease.

For Comparison of pulmonary artery, aortic diameter and ratios between two groups Mann Whitney U test
was used. There was statistically significant difference in the diameters such as MPA, RPA, LPA, AAO and DAO
(p<0.001) between COPD and controls. But there was no statistically significant difference in ratios such as MPA/
AAO and MPA/DAO between COPD cases and controls (p >0.001). Main pulmonary artery, right pulmonary
artery, left pulmonary artery diameter, Ascending Aorta, Descending Aorta were larger in COPD group compared to
control group. (Fig. 3)

Fig. 3: Comparison of MPA, RPA, LPA, AAo and DAo diameters between COPD and non–COPD

Receiver operating characteristic (ROC) curve was used to find sensitivity and specificity of diameters
measured using CT in predicting COPD (Fig. 4). Sensitivity and specificity of measured pulmonary artery, aortic
diameters and ratio’s for predicting COPD were evaluated (Table 2). MPA, RPA, LPA measured using CT were
found to have greater accuracy in predicting COPD. Among the three measurements MPA has highest sensitivity
and specificity in detecting COPD
Fig. 4: Receiver operating characteristic (ROC) curves showing the diagnostic accuracy of different CT
measurements for COPD

Table 2: Area under the curve, sensitivity and specificity of pulmonary artery, aortic diameters
for predicting COPD
Diameters AUC Sensitivity(%) Specificity(%)
MPA 0.681 77.3 83
RPA 0.737 74.8 79.5
LPA 0.682 71.8 78.8
AAo 0.646 56.7 42.6
Dao 0.599 30.1 60.3
MPA/AAo 0.532 17.3 33.8
MPA/DAo 0.568 18.9 33.8
MPA – Main Pulmoary Artery,RPA - Right In our study we found that there was significant
Pulmonry Artery, LPA – Left Pulmonary Artery, AAo – difference in pulmonary artery diameters and aortic
Ascending Aorta, DAo – Descending Aorta diameters between case and controls with MPA, RPA,
LPA diameters and width of AAo and DAo larger in
Intra- observer variability: There was no stastically COPD cases than those in the controls. The ratios of
significant difference between the measurements MPA/AAo and MPA/DAo was also calculated but there
performed by Reader A and B at different time periods, was no but there was no significant difference between
according to paired student’s t-test (p<0.001) two groups.
Inter-observer variability for the above Madas et al, reported that the diameters of main
measurements, the Kappa value was 0.97, suggesting pulmonary artery, right pulmonary artery and left
good agreement and reproducibility. pulmonary artery were significant higher in COPD group
than the controls, but there was not much of difference
Discussion in the ascending aorta and descending aorta diameters
COPD is a chronic inflammatory disease which between the two sets of patients .
8

affects the structure and the function of the lung. CT In a study conducted by Lee SH et al, Main
is an important imaging tool to evaluate different pulmonary artery and Ascending aorta diameter was
characteristics and clinical outcomes in patients with measured using CT in healthy Korean population. Mean
COPD7. MPA and Ao was 25.9mm and 30.0 mm respectively
and the mean MPA/Ao ratio was 0.87 9. In our
study
mean MPA and Ao was 24.0 and 30.1 respectively and 3. World Health Organization. Burden of COPD.
the mean MPA/Ao ratio was 0.80 in healthy individual Available from: http://www.who.int/repiratory/
which is concordant with previous study. copd/burden/en/
Chen et al, reported that MPA could be used as 4. Koul PA. Chronic obstructive pulmonary disease:
best index for predicting COPD with threshold Indian guidelines and the road ahead. Lung India:
value Official Organ of Indian Chest Society. 2013
27.5mm, AUC 0.711, specificity 54% and sensitivity Jul;30(3):175.
80%. RPA was selected as best index for predicting
5. Berg K, Wright JL. The pathology of chronic
COPD-PH with threshold value 23.4 mm, area under
obstructive pulmonary disease: progress in the
the curve 0.806, specificity 67% and sensitivity 76%10.
20th and 21st centuries. Archives of pathology &
However, in this present study MPA, RPA, LPA
laboratory medicine. 2016;140(12):1423-8
measured using CT were found to have greater accuracy
in predicting COPD. Among the three measurements 6. Whiting P, Singatullina N, Rosser JH. Computed
MPA has highest sensitivity71.3% and specificity 83% tomography of the chest: I. Basic principles. Bja
in predicting COPD. Education. 2015;15(6):299-304.
7. Hahm CR, Lim MN, Kim HY, Hong SH, Han
Conclusion SS, Lee SJ, Kim WJ, Hong Y. Implications of
the pulmonary artery to ascending aortic ratio in
Our study concludes that, there was a significant
patients with relatively mild chronic obstructive
difference in pulmonary artery and aortic diameters
pulmonary disease. Journal of thoracic disease.
between COPD patients and control group. Main
2016;8(7):1524.
Pulmonary Artery diameter measured using CT had
highest sensitivity and specificity in predicting COPD. 8. Madas S, Vittal DS. Estimation of measured
Therefore, Main Pulmonary artery, Right and left pulmonary artery to aorta ratio for prognosis of
pulmonary artery diameter measured using CT could be pulmonary hypertension in chronic obstructive
useful as the indices for the diagnosis of COPD. pulmonary disease patients. International Journal
of Advances in Medicine. 2017;3(2):200-5.
Ethical Clearance: The ethical approval for the study
was obtained from Institutional Ethics Committee (IEC 9. Lee SH, Kim YJ, Lee HJ, Kim HY, Kang YA,
No. - 133/2018) Park MS, et al. Comparison of CT-determined
pulmonary artery diameter, aortic diameter,
Source of Funding: Self and their ratio in healthy and diverse clinical
conditions. PLoS One.2015;10(5):1–13.
Conflict of Interest: nil
10. Chen X, Liu K, Wang Z, Zhu Y, Zhao Y, Kong
H, Xie W, Wang H. Computed tomography
REFERENCES
measurement of pulmonary artery for diagnosis
1. Devine JF. Chronic obstructive pulmonary of COPD and its comorbidity pulmonary
disease: an overview. American health & drug hypertension. International journal of chronic
benefits. 2008 ;1(7):3 obstructive pulmonary disease. 2015; 10:2525
2. Global Strategy for the Diagnosis, Management,
and Prevention of Chronic Obstructive Pulmonary
Disease. Available from: http://www.goldcopd.org
DOI Number: 10.5958/0976-5506.2019.01593.6

Acute Anticonvulsant Activity of Diltiazem, Nimodipine and

Flunarizine in Wistar Albino Rats by Maximum Electroshock-
Induced Seizure

Saniya K1, BG Patil2, Madhavrao3, Prakash KG4

1
Assistant Professor, Department of Anatomy, Azeezia Institute of Medical Sciences and Research,
Kollam, Kerala, India; 2Professor, Department of Anatomy, Shri B M Patil Medical College, BLDE
University, Vijayapura, Karnataka state, India; 3Professor, Department of Pharmacology, 4Professor and
Head, Department of Anatomy, Azeezia Institute of Medical Sciences and Research, Kollam, Kerala, India

ABSTRACT
Background and objectives: In spite of growing armamentarium of antiepileptic drugs, many patients
continue to have seizures. This propels for search of novel and safe drugs for resistant and recurrent
convulsions. Calcium channel blockers have been ascribed with anticonvulsant actions. The objective of
the present study was to evaluate the anticonvulsant actions of diltiazem, nimodipine and flunarizine among
Wistar albino rats in Maximum Electroshock-induced Seizure (MES) model.
Methodology: Thirty inbred Wistar rats weighing 150-200 grams of either sex, divided into five groups
containing six rats in each. Group 3, 4 and 5 were pre-treated with diltiazem (20mg/kg), nimodipine (20mg/
kg) and flunarizine (10mg/kg) respectively. Group 2 was standard group, received phenytoin (25mg/kg).
The groups pre-treated with calcium channel blockers were compared with this standard. Group 1 was
negative control and were given normal saline. All groups were subjected to MES. During and after the
MES, the duration of flexion, duration of tonic hind limb extension and duration of clonus (in seconds)
were noted. Abolition of hind limb extension and reduction (or absence) of the clonus duration after the
drug administration were considered as anticonvulsant effect of the test drug.
Results: Rats pre-treated with diltiazem, nimodipine, flunarizine showed statistically significant reduction
in duration of hind limb extension phase and clonic seizures. Total duration of the seizures was also
significantly lower and comparable to phenytoin pre-treated rats. All rats in all groups survived the
experiments indicating the doses used during the study were not lethal
Conclusions: Diltiazem (20mg/kg), nimodipine (20mg/kg) and flunarizine (10mg/kg) have anticonvulsant
action among Wistar rats in MES model.

Keywords: Calcium channel blockers; anticonvulsant; seizure; epilepsy; diltiazem; nimodipine;

flunarizine;
maximum electroshock model

Introduction
In spite of availability of considerable number of
Corresponding Author: anti-epileptic drugs, many patients continue to have
Saniya K seizures that are refractory to treatment defying our
Assistant Professor, Department of Anatomy, understanding and approaches of epilepsy1. In the search
Azeezia Institute of Medical Sciences and Research, for a novel anticonvulsant drugs, many plant extracts
Kollam, Kerala, India and old drugs are evaluated for newer indications. With
Phone: +919048533410 increasing understanding of epileptogenic molecular
Email: [email protected] mechanisms, more avenues are opening.
358 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 358

Many of the currently used anti-epileptic drugs are 25° ± 1 °C and relative humidity of 41.55%. A 12:12,
shown to inhibit calcium channel activity2,3. Theoretical light: dark cycle was following during the experiment.
considerations and few animal model studies have The experiment was carried out during 1200-1400 hr.
suggested that calcium channel antagonists may play a Animals had free access to food and water. However,
role as anticonvulsants4. These drugs are postulated to food but not water was withdrawn 8hr before and during
inhibit the positive inward burst firing activating wide the experiments.
range of neurons leading to seizures. To support such
theoretical considerations, few animal model studies and Institutional animal ethics committee, BLDEU’s
clinical studies have shown that nimodipine has Shri B M Patil Medical College, Vijayapura, Karnataka
anticonvulsant property5,6. Combination of calcium state, (with CPCSEA, India registered) (approval letter
channel blockers was shown to have mixed effects. number: 32/16, dated-16.01.2016) and also Institutional
Diltiazem enhances the nimodipine’s antiseizure effects. animal ethics committee, KMCH College of Pharmacy,
Flunarizine inhibits nimodipine’s effects7. During last Coimbatore, Tamil Nadu, (approval letter number:
decade of twentieth century, there was heightened KMCRET/PhD/05/16-17, dated-22.02.2016) approved
interest in evaluation of calcium channel blockers for the study before the start of the study
epilepsy at least in animal model. There were series of
research reports pertinent to this area8–12. After the Evaluation of anticonvulsant activity-Maximum
introduction of gabapentin, topiramate, tiagibine, electroshock (MES) model: The rats were pretested
levetiracetam and zonisamide, the evaluation of prior to the drug administration for the electroshock
monotherapy for epilepsy has veined13–15. However, the sensitivity. Convulsions were induced by using electro-
evaluation continued as add on therapy both in animal convulsiometer (Techno India Ltd). MES stimulation
model and in clinical trials16–19. were given using trans-auricular (ear-clip) electrodes
from the apparatus. Intensity of MES was at 150mA for
There are many animal models have been developed 0.2 seconds, with constant voltage stimulators of 250 V.
over the previous two decades for evaluation of the novel At this intensity and duration all the control group rats
anti-epileptic drugs. The maximal electroshock (MES) exhibited tonic hind limb extension. Only those rates
model remains as an important gatekeeper for such that consistently exhibited the tonic hind lime extension
evaluation, in spite of the fact that it failed in
in three trials on three separate days were used for the
levetiracetam efficacy20. MES model has been
study21.
successfully used to prove the anticonvulsant action of
plethora of plant extracts21. However, the evaluation of Rats were divided onto five groups of six each. The
calcium channel blockers alone was done in limited division and administration of the drugs are tabulated in
number of studies. Sahadevan has shown the the Table 1. All groups were subjected to MES.
anticonvulsant action of nimodipine and flunarizine in
mice MES model22. Diltiazem anticonvulsant effects
Table 1: Description of groups and drugs
were hitherto unevaluated in Indian set up in rat MES
administered during the study (n = 30)
model.
Group Description Drug administered
The objective of the study was to evaluate the
Normal saline equivalent
anticonvulsant effect of diltiazem, nimodipine and I Control group
(PO)
flunarizine in Wistar albino rats using MES model. Phenytoin sodium 25 mg/
II Standard group
kg body weight
Methodology III Diltiazem group Diltiazem 20mg/kg (PO)
Experiments were conducted with 36 inbred Wister IV Nimodipine group Nimodipine 20mg/kg (PO)
rats, in 3–4 weeks old, weighing 150-200 grams, V Flunarizine group Flunarizine 10mg/kg (PO)
of either sex, were used in this study. All rats were
During and after the MES, the duration of flexion,
obtained from animal house, BLDEU’s Shri B M Patil
duration of tonic hind limb extension and duration of
Medical College, Vijayapura, Karnataka state. Animals
clonus (in seconds) were noted.
were group housed in cages of six with water and food
supplied ad libitum. The temperature was maintained at
Abolition of hind limb extension and reduction Results
(or absence) of the clonus duration after the drug
administration were considered as anticonvulsant effect MES induced seizures: Following the ear electrode
of the test drug. stimulus, an immediate tonic seizure with hind limb
extension was observed in all animals of group I and
Statistical analysis: The data obtained was expressed group II. There were no signs of toxicity in the control
as mean ± standard deviation. Comparison of the data groups. The positive control group administered with
was done by one-way ANOVA, followed by Dunnett phenytoin did not show the phase of clonic seizures. The
comparison. P value of less than 0.05 was taken as latency of onset of flexion, extension and clonic seizures
significant. is tabulated in Table 2.

Table 2: Tabulation of latency and duration of seizures (expressed as mean ± standard deviation in seconds)
in all the groups of rats in MES model (n = 36)
Time in seconds Recovery/
Group Flexion Extension Clonus Duration mortality
Only MES 8.167 ± 0.47 11.167 ± 3.75 20.667 ± 4.35** 107 ± 23.84 Recovery
MES+ Phenytion 25 mg/kg 1.2 ± 0.68 4.83 ± 1.66* 0 43 ± 9.33* Recovery
MES + Diltiazem 20mg/kg 1.16 ± 0.47 1.5 ± 1.5† 4 ± 2.543* 67.16 ± 14.06† Recovery
MES + Nimodipine 20mg/kg 1.5 ± 0.67 3.5 ± 2.21† 5.5 ± 3.86* 69 ± 14.66† Recovery
MES + Flunarizine 10mg/kg 1.02 ± 0.68 3 ± 1.91† 13.6 ± 6.28† 75.66 ± 5.40† Recovery
Rats pre-treated with diltiazem, nimodipine, was shown to have anticonvulsant actions in many
flunarizine showed statistically significant reduction in other studies in the past 15,19. In addition, diltiazem has
duration of hind limb extension phase and clonic been shown to enhance the actions of oxcarbazepine 14
seizures. Total duration of the seizures was also and topiramate19. In the similar way, amlodipine has
significantly lower and comparable to phenytoin pre- been shown to be anticonvulsant when used singly 9,11,15.
treated rats. All rats in all groups survived the Amlodipine also enhances the anticonvulsant actions of
experiments indicating the doses used during the study lamotrigine, gabapentin and topiramate13,16,19.
were not lethal.
With patients continuing to have recurrent episodes
of convulsions while on anticonvulsant therapy, the
Discussion
search for novel and safe effective in such resistant
Calcium channels, both L-type and T-type has been individuals endures. In this study an attempt was
increasingly implicated in epileptogenesis 2–4,23. It is made to show the anticonvulsant effects of three
postulated that calcium channel antagonists have anti- calcium channel blockers – diltiazem, nimodipine and
seizure and neuroprotective roles. Many previous studies flunarizine. The effects in MES model, however, need
have demonstrated such anti-seizure actions of calcium not necessarily translate to the clinical effects in epileptic
channel blockers in rat MES model. Nifedipine (in doses individuals. Further tests, both animal model and pre-
of 10mg/kg), amlodipine (in doses of 1-4mg/kg)11,12,16, clinical tests, evaluating the neurotransmitter levels in
felodepine (in doses of 5-10 mg/kg) 10, verapamil (in the specific areas of the brain, pathological alterations
doses of 5 mg/kg)5,15,19, flunarizine(in doses of 5 mg/ in the neuronal cells structure and functions as proven
kg)17,18, nicardipine (in doses of 5 mg/kg)17, nimodipine at least by histological and immunohistopathological
(in doses of 5-10 mg/kg) 5,6,17,18 and diltiazem (in doses studies shall add to the findings of the present study. The
of 5-10 mg/kg) have been shown to have anti-seizure handling of free radicals in the brain and consequent
actions in animal models. In the present study as well, brain inflammation has been postulated as potential
diltiazem, nimodipine and flunarizine were proven to
epileptogenic mechanism24. Studies evaluating the
have anti-seizure actions.
oxidative stress, both in animal model and preclinical
Contrary to our findings, diltiazem was shown set up using these drugs shall make calcium channel
to have no anticonvulsant action even with increasing blockers potential drugs for epilepsy.
doses among mice MES model22. However,
diltiazem
Limitations of the study: Use of multiple animal Rogawski MA, Olsen RW, Delgado-Escueta
models nullifies short comings of each other and AV, editors. Jasper’s Basic Mechanisms of the
achieves better clinical correlations in humans. Dose Epilepsies [Internet]. 4th ed. Bethesda (MD):
variations during MES model would have provided National Center for Biotechnology Information
minimum effective dose (ED50) of the drugs. Use of (US); 2012 [cited 2019 Jun 5]. Available from:
standard anti-epileptic drug in each group would have http://www.ncbi.nlm.nih.gov/books/NBK98147/
evaluated the additive role the calcium blockers.
4. Kułak W, Sobaniec W, Wojtal K, Czuczwar SJ.
Currently only calcium channel blockers are used –
Calcium modulation in epilepsy. Pol J Pharmacol.
that are rarely clinically used as standalone therapy for
2004 Feb;56(1):29–41.
epilepsy.
5. Wurpel JN, Iyer SN. Calcium channel blockers
Conclusions verapamil and nimodipine inhibit kindling
in adult and immature rats. Epilepsia. 1994
Diltiazem (20mg/kg), nimodipine (20mg/kg) and Apr;35(2):443–9.
flunarizine (10mg/kg) have anticonvulsant action among 6. Moreno LCG e AI, Cavalcanti IMF, Satyal P,
Wistar rats in MES model Santos-Magalhães NS, Rolim HML, Freitas RM.
Acute toxicity and anticonvulsant activity of
Acknowledgements liposomes containing nimodipine on pilocarpine-
induced seizures in mice. Neurosci Lett. 2015 Jan
The authors thank the animal house in-charge of
12;585:38–42.
BLDEU’s Shri B M Patil Medical College, Vijayapura,
Karnataka state and also the animal house, KMCH 7. Morón MA, Stevens CW, Yaksh TL. Diltiazen
College of Pharmacy, Coimbatore,Tamil Nadu. enhances and flunarizine inhibits nimodipine’s
antiseizure effects. Eur J Pharmacol. 1989 Apr
Conflict of Interest: Authors declare no conflict of 25;163(2):299–307.
interest
8. El-Azab MF, Moustafa YM. Influence of
Source of Funding: Nil calcium channel blockers on anticonvulsant and
antinociceptive activities of valproic acid in
Ethical Clearance: Institutional animal ethics pentylenetetrazole-kindled mice. Pharmacol Rep
committee, BLDEU’s Shri B M Patil Medical PR. 2012;64(2):305–14.
College, Vijayapura, Karnataka state, (with CPCSEA,
9. Sathyanarayana Rao KN, Subbalakshmi NK. An
India registered) (approval letter number: 32/16,
experimental study of the anticonvulsant effect
dated-16.01.2016) and also Institutional animal ethics
of amlodipine in mice. Singapore Med J. 2010
committee, KMCH College of Pharmacy, Coimbatore,
May;51(5):424–8.
Tamil Nadu, (approval letter number: KMCRET/
PhD/05/16-17, dated-22.02.2016) approved the study 10. Kishore M S, Pushpa V H, Padmaja Shetty K,
before the start of the study Kalabharathi H L, Satish A M. Evluation of the
antiepileptic activity of felodepine in albino mice.
Int J Pharm Pharm Sci. 2014;6(6):498–500.
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1. Wilcox KS, Dixon-Salazar T, Sills GJ, Ben- 11. B R, M J, Y VR. Evaluation of anticonvulsant
activity of amlodipine in albino rats. Int J Basic
Menachem E, White HS, Porter RJ, et al. Issues
Clin Pharmacol. 2017 Feb 24;6(3):664–8.
related to development of new anti-seizure
treatments. Epilepsia. 2013 Aug;54(0 4):24–34. 12. Jagathi Devi N, Prasanna V. Effect of amlodipine
and indomethacin in electrical and picrotoxin
2. Kopecky BJ, Liang R, Bao J. T-type Calcium
induced convulsions in mice. Int J Med Res
Channel Blockers as Neuroprotective Agents.
Health Sci 201433592-596.
Pflugers Arch. 2014 Apr;466(4):757–65.
13. Hassan M, Masoud A. Effect of amlodipine on
3. Cain SM, Snutch TP. Voltage-Gated Calcium
the antiepileptic action of lamotrigine, gabapentin
Channels in Epilepsy. In: Noebels JL, Avoli
M,
and topiramate on maximal electroshock induced 19. Luszczki JJ, Trojnar MK, Trojnar MP, Kimber-
seizures in mice. Natl J Physiol Pharm Pharmacol. Trojnar Z, Szostakiewicz B, Zadrozniak A, et al.
2014;4(3):201. Effects of amlodipine, diltiazem, and verapamil
14. Zadrożniak A, Trojnar M, Trojnar M, Kimber- on the anticonvulsant action of topiramate against
Trojnar Ż, Dudra-Jastrzębska M, Andres-Mach maximal electroshock-induced seizures in mice.
M, et al. Diltiazem enhances the protective Can J Physiol Pharmacol. 2008 Mar;86(3):113–21.
activity of oxcarbazepine against maximal 20. French JA, White HS, Klitgaard H, Holmes GL,
electroshock- induced seizures in mice. J Pre- Privitera MD, Cole AJ, et al. Development of new
Clin Clin Res. treatment approaches for epilepsy: unmet needs
2008 Dec 9;2(2):147–52. and opportunities. Epilepsia. 2013 Aug;54
15. Luszczki JJ, Trojnar MK, Trojnar MP, Kimber- Suppl
Trojnar Z, Szostakiewicz B, Zadrozniak A, et 4:3–12.
al. Effects of three calcium channel antagonists 21. Castel-Branco MM, Alves GL, Figueiredo
(amlodipine, diltiazem and verapamil) on the IV, Falcão AC, Caramona MM. The maximal
protective action of lamotrigine in the mouse electroshock seizure (MES) model in the
maximal electroshock-induced seizure model. preclinical assessment of potential new
Pharmacol Rep PR. 2007 Dec;59(6):672–82. antiepileptic drugs. Methods Find Exp Clin
16. Kamiński RM, Mazurek M, Turski WA, Kleinrok Pharmacol. 2009 Mar;31(2):101–6.
Z, Czuczwar SJ. Amlodipine enhances the activity 22. P. Sahadevan, M.N. Rema. A comparative
of antiepileptic drugs against pentylenetetrazole- experimental study of the anticonvulsant effect
induced seizures. Pharmacol Biochem of three calcium channel blockers in albino mice.
Behav. Indian J Pharmacol. 2002;34:52–5.
2001 Apr 1;68(4):661–8.
23. Köhling R, Straub H, Speckmann EJ. Differential
17. Czuczwar SJ, Gasior M, Janusz W, Kleinrok involvement of L-type calcium channels in
Z. Influence of flunarizine, nicardipine and epileptogenesis of rat hippocampal slices during
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of different antiepileptic drugs in mice. 82.
Neuropharmacology. 1992 Nov;31(11):1179–83.
24. Aguiar CCT, Almeida AB, Araújo PVP, de
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Z, Czuczwar SJ. Influence of nicardipine, Oxidative Stress and Epilepsy: Literature Review.
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1996;103(7):819–31.
DOI Number: 10.5958/0976-5506.2019.01594.8

Isolated and Combined Effect of Plyometric and Weight

Training on Selected Physical Fitness and Hematological
Variables of Football Players

K. S. Saran1, K. Vaithianathan2, Mithin Anand1, T. Arun Prasanna1

1
Ph.D. Scholar, 2Director of Sports, Dept. of Physical Education and Sports Science, SRMIST,
Kattankulathur

ABSTRACT
In this research eighty football players were selected as samples from colleges under M.G University,
Kottayam. And the variables selected were Physical fitness variables- speed and explosive power and
Hematological variables-RBC count and Hemoglobin percentage. After employing 12 weeks of isolated
and combined plyometrics and weight training for selected subjects who were divided into four groups, a
significant difference was observed in all selected variables. There is also significant difference among the
groups after applying Scheffe’s post hoc test.

Keywords: Physical fitness, Speed, Explosive power, Hematological variables, RBC count, Hemoglobin
percentage
Introduction which is one of the most effective training to bring up
explosive power. 5 Studies have found that resistance
In ancient times, our ancestors showed
training is effective and safe training method to develop
extraordinary talent in terms of physical activity in olden
hypertrophic increase in youth athletes. Similarly, if
days. Sports and games have turned into professional
done properly plyometric training exhibits greater
dimension due to the tough competitions in the fields. 1
increase performance variables of an athletes.6 A
People have started involving in various sports idea
combination of these two method training can improve
irrespective of their age to be creative and
performance to greater extent.
competitive. Participation and practice alone don’t help
in the success of an individual. The quality of a sports Subjects’ Selection: For the purpose of the study eighty
life has been affected through various factors such as football players was chosen as samples from colleges
physiology, sports training, sociology, computer under M.G University, Kottayam.
technology.2
Selection of Variables
Sports training are now one of the most closely
watched research streams of all time.3 Aim to excel in Physical fitness variables: speed and explosive power
maximum performance and achieving goals at desirable and
time is always the prime objective. In sports population Hematological variables: RBC count and
resistance training has shown to impel a positive Hemoglobin
hypertrophic, neuromuscular and strength improvement percentage
everywhere around the world.4 Plyometric training
Selection of Test: The following standard test will be
administrated to collect relevant data from the subjects.
Corresponding Author: Speed-50m Dash, explosive power-standing broad
K. S. Saran jump,RBC count and hemoglobin percentage laboratory
Ph.D Scholar, test.
Dept. of Physical Education and Sports Science,
Experimental Design
SRMIST, Kattankulathur
Email: [email protected] z The random group design will be experimental
design. A random selection of 80 subjects 20
into
4 groups three experimental where combined
and
363 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 363

isolated training were given. The last one was Group 3- Isolated training –Plyometric training
considered as control group and no training were
given. Group 4- No workout

z Experimental Group 1 Combined Plyometrics + Isolated Plyometric training -3 days per week
weight training
Isolated Circuit training - 3 days per week
z Experimental Group 3 weight training - isolated
training Combined training - 3 days per week

z Experimental group 2 plyometrics training - Statistical Technique: The data collected from the
isolated training subjects after the 12 weeks of training was analyzed
z Group D Control group statistically with the analysis of covariance (ANCOVA)
to evaluate the differences, if occurring, between the
Training Protocol groups on chosen dependent variables individually. If
attained ‘F’ ratio for the post test adjusted was
No. of training weeks: 12 weeks
significant, the Scheffe’s test was used as post hoc test
Group 1- Combined training- plyometric and circuit for finding out paired mean differences. The confident
training level was maintained at 0.05 to determine the
significance to be appropriate. The results using
Group 2- Isolated training- weight training Analysis of co-variance and post hoc value are listed in
table I and II.

Result

Table I: Computation of Analysis of Covariance

Variable Group Pretest Posttest Df

F
Mean Sd Mean Sd Between Within
Ex 1 7.07 0.15 6.92 0.14
Speed Ex 2 7.10 0.22 6.55 0.28
3 76 21.79*
Ex 3 7.06 0.35 6.93 0.25
Ctrl 7.10 0.18 7.09 0.16
Ex 1 2.46 0.10 2.67 0.14
Explosive Ex 2 2.35 0.22 2.45 0.21
3 76 14.70*
Power Ex 3 2.31 0.15 2.48 0.12
Ctrl 2.29 0.17 2.32 0.16
Ex 1 4.94 0.37 5.85 0.17
Ex 2 5.16 0.30 5.90 0.09
RBC count 3 76 70.43*
Ex 3 4.90 0.30 5.53 0.28
Ctrl 4.86 0.27 4.97 0.30
Ex 1 14.63 0.57 15.68 0.59
Haemoglobin Ex 2 14.59 0.59 15.46 0.56
3 76 17.62*
Count Ex 3 14.31 0.50 14.47 0.75
Ctrl 14.45 0.52 15.08 0.54

Table value required for significance at 0.05 confident level for 3 and 76 is 2.728.
Table II: Post-hoc value
Variable Ex1 & Ex2 Ex1 & Ex3 Ex1 & Ctrl Ex2 & Ex3 Ex2 & Ctrl Ex3 & Ctrl CI value
Speed 0.38 0.02 0.15 0.4 0.53 0.13 0.57
Explosive Power 0.25* 0.19* 0.35* 0.06 0.10 0.16* 0.15
RBC count 0.03 0.32 0.87* 0.35 0.90* 0.55 0.47
Hb Count 0.2 0.78* 0.73* 0.58* 0.53 0.05 0.56

Significance at 0.05 confident level

Discussion and Conclusion 2. Helsen WF, Starkes JL, Hodges NJ. Team
sports and the theory of deliberate practice.
The results from table I indicated that ‘F’ value
Journal of Sport and Exercise psychology. 1998
obtained for speed, explosive power, RBC count and
Mar;20(1):12-34.
haemoglobin count are significant as the values found
greater than 2.72 which is the required table value for at 3. De Bosscher V, De Knop P, Van Bottenburg M,
0.05 significant level. Scheffe’s post-hoc test Shibli S. A conceptual framework for analysing
indicated sports policy factors leading to international
the following results sporting success. European sport management
quarterly. 2006 Jun 1;6(2):185-215.
z Speed: no significant difference between adjusted
mean between the four group 4. Mistry AD. Effects of Yoga on Low Back
z Explosive power: significant difference among Stability, Strength and Endurance (Doctoral
Group 1 and 2, group 1 and 3, and group 1 and dissertation, Virginia Tech).
control group. 5. Bruce-Low S, Smith D. EXPLOSIVE
EXERCISES IN SPORTS TRAINING: A
z RBC count: significant difference among Group
1 CRITICAL REVIEW. Journal of Exercise
and control group; group 2 and control group. Physiology Online. 2007 Feb 1;10(1).

z Hb count: significant difference between Group 1 6. Lyttle AD, Wilson GJ, Ostrowski KJ. Enhancing
and 3, group 1 and control group, and group 2 and performance: Maximal power versus combined
3. weights and plyometrics training. Journal of
Strength and Conditioning Research. 1996 Aug
Ethical Clearance: Nil 1;10:173-9.
Source of Funding: Self

Conflict of Interest: Nil

REFERENCES
1. Larson RW. Toward a psychology of positive
youth development. American psychologist. 2000
Jan;55(1):170.
DOI Number: 10.5958/0976-5506.2019.01595.X

Effect of Game Specific Circuit Training and Plyometrics

on Selected Physiological and Hematological Variables of
Handball Players

Mithin Anand1, K. Vaithianathan2, K. S. Saran1, T. Arun Prasanna1

1
Ph.D Scholar, 2Director of Sports, Dept. of Physical Education and Sports Science, SRMIST,
Kattankulathur

ABSTRACT
To achieve the purpose of this study, 64 intercollegiate level handball players from M.G University,
Kottayam were selected as subjects. The variables selected of this research were Physiological variables
namely Vital capacity and respiratory rate and Hematological variables like RBC count and Hemoglobin
count. After engaging twelve weeks of game specific circuit training and plyometrics for selected subjects,
divided into four groups. The findings revealed that there was a difference significantly in all selected
variables. After applying the test of Scheffe’s post hoc, it was found that there is significant differences
between groups were found.

Keywords: Hand ball, Vital capacity, Respiratory rate, RBC count, Hemoglobin
count
Introduction and coaches develop their techniques and strategies.5
The frequent breaking of national and international
Sport is a form of physical activity which involves
records was possible by these technological and
skills for a competition or entertainment by casual or
tactical advancements in the sports field. The scientific
organized involvement of participants.1 It is an event
examinations in the performance by the athletes are
that provides physical fitness through joyful activities.
playing an imperative role in evaluating the success. The
The modern civilization gives immense recognition
popularity and the place of prominence of sports and
to sports and physical fitness which leads to the good
games are in fastest pace which it has gained from past
establishments of the organization of sports.2 The sports
decades by the hard works of sportspersons, coaches,
play a significant role in contemporary society in terms
researchers, media, organizers etc.6
of awareness about health and fitness, entertainment,
profession, money etc.3 Subjects and Variables Selection: To achieve the
purpose of this study, sixty-four intercollegiate level
The present scenario of competitive sports is
handball players from M.G University, Kottayam were
being portrayed by professionalism at the different
selected as subjects.
levels of competitions. The desires of the athletes for
earning fame and wealth is the contributing factor of The variables selected of this research were
the professionalism.4 Scientific preparations of the Physiological variables namely Vital capacity and
sportspersons for the competitions play a vital role respiratory rate and Hematological variables like RBC
in the enhancement of the performances. To display count and Hemoglobin count.
the upper hand against the opponent the researchers
Selection of test

Vital capacity Spirometry (using wet spirometer)

Corresponding Author:
Mithin Anand Respiratory Chest-abdomen expansion
test monitoring test
Ph.D Scholar,
Dept. of Physical Education and Sports Science, RBC count CBC test (Laboratory test)
RMIST, Kattankulathur Haemoglobin
CBC test (Laboratory test)
Email: [email protected] count
366 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 366

Experimental Design: The comparative group design Training Protocol

was the design of the study of this research. The total
number of chosen subjects was put to an equal division No. of training weeks: 12 weeks
of four groups. Three experimental groups namely Game Isolated Plyometric training -3 days per week
specific circuit training group, plyometric training group Isolated Circuit training -3 days per week
and a combined plyometric- game specific circuit training Combined training -3 days per week
group and the fourth group was controlled group.
Statistical Technique: After the twelve-week training
z Group A– Experimental : Plyometric and programme, the data were examined statistically by
circuit with the analysis of covariance (ANCOVA) to evaluate
training (Combined training) the significant differences. The test of Scheffe’s post-
z Group B – Experimental : Plyometric training hoc was used to determine the paired mean differences,
(Isolated training) if ‘F’ ratio for the adjusted post test was found to be
significant. The level of confidence will be fixed at 0.05
z Group C– Experimental : Circuit training (Isolated
to evaluate the significance. The results obtained were
training)
present in the table I and table II.
z Group D – Control : No training

Result

Table I: Descriptive statistics and Computation of Analysis of Covariance

Variable Group Pretest Posttest Df
F
Mean Sd Mean Sd Between Within
Ex 1 3356 292.61 4840 257.69
Vital capacity Ex 2 3378 280.45 4718 248.24
3 60 144.74*
Ex 3 3381 292.04 3509 255.09
Ctrl 3331 269.49 3359 276.41
Ex 1 15.50 1.46 12.06 1.23
Respiratory Ex 2 15.31 1.30 11.68 0.60
3 60 35.14*
rate Ex 3 15.31 1.74 14.87 1.14
Ctrl 15.56 2.03 15.00 1.59
Ex 1 4.95 0.21 5.65 0.36
Ex 2 4.96 0.25 5.85 0.18
RBC count 3 60 26.90*
Ex 3 5.03 0.25 5.51 0.28
Ctrl 4.95 0.26 4.94 0.38
Ex 1 14.56 0.52 15.62 0.64
Haemoglobin Ex 2 14.60 0.58 15.44 0.57
3 60 11.77*
Count Ex 3 14.32 0.51 14.45 0.51
Ctrl 14.45 0.52 14.79 0.78
Required table value for significance at 0.05 confident level for 3 and 60 is 2.76.

Table II: Post-hoc value

Variable Ex1 & Ex2 Ex1 & Ex3 Ex1 & Ctrl Ex2 & Ex3 Ex2 & Ctrl Ex3 & Ctrl CI value
Vital capacity 125.74 1335.67* 1476.84* 1209.93* 1351.1* 141.17 261.30
Respiratory rate 0.32 2.868 2.92* 3.18* 3.24* 0.06 1.15
RBC count 0.2 0.14 0.72* 0.34* 0.92* 0.58* 0.31
Hb Count 0.19 1.16* 0.82* 0.97* 0.63 0.34 0.65

Significance at 0.05 confident level

Discussion and Conclusion REFERENCES
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significant difference between Group 1 and 3, group 1 3. Maguire JS. Leisure and the obligation of self‐
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control group. In Respiratory rate, significant studies. 2008 Jan 1;27(1):59-75.
difference was observed between Group 1 and 4. Duda JL. Relationship between task and ego
control group, group orientation and the perceived purpose of sport
2 and 3, and group 2 and control group. Significant among high school athletes. Journal of sport and
difference in RBC are between Group 1 and control exercise psychology. 1989 Sep;11(3):318-35.
group, and group 2 and 3, group 2 and control group,
5. Kapp KM. The gamification of learning and
group 3 and control group. In Hb count the significant
instruction: game-based methods and strategies for
difference between Group 1 and 3, group 1 and control
training and education. John Wiley & Sons; 2012.
group, and group 2 and 3.
6. Siedentop DL, Hastie P, Van der Mars H.
Ethical Clearance: Nil Complete guide to sport education. Human
Source of Funding: Self Kinetics; 2019 Feb 28.

Conflict of Interest: Nil

DOI Number: 10.5958/0976-5506.2019.01596.1

“A Study to Assess Coping Stratergies among Parents of

Mentally Challenged Children at Selected Special Schools of
Miraj, Kupwad and Kolhapur Corporation Area”

Akshay Bhupal Pawar1, Rajesh Gaikwad2

1
Final Year M.Sc. Nursing, 2Clinical Instructor, M.Sc Nursing (Psychiatric
Department), College of Nursing Sangli, Bharati Vidyapeeth (Deemed to be) University

ABSTRACT
A quantitive study was conducted by Mr. Akshay. B. Pawar In partial fulfillment of the requirement for the
award of Master of Science degree in nursing, Bharati Vidyapeeth (Deemed to be) University, Pune.
Aims:
1. To assess the coping strategies adopted by parents of mentally challenged children.
2. To find out association between the coping strategies with selected demographic variables
Materials and Method: Non-experimental descriptive research design was used to assess the coping
strategies among parents of mentally challenged children at selected special schools of Miraj, kupwad and
Kolhapur corporation area. The reliability coefficient “r” of the coping strategy rating scale was 0.9, hence
it was found reliable. Total 100 samples were selected by Non- Probability purposive sampling method.
A coping strategy rating scale of 25 items was administered to assess coping strategies among parents of
mentally challenged children. The conceptual framework based on the Roy’s Adaption theory, developed
by Sister Callista Roy which consists of four major concepts i.e. Input, Control process, Effectors and
Output through which the individual cope with the stressors
Results and Conclusion: The study revealed that the parents of mentally challenged children were using
some coping strategies i.e. are watching TV or going for film with family members i.e.(54%); trying to
found several alternatives i.e.(53%); reducing household budget i.e.(51%); sharing difficulties with friends
and relatives i.e.(55%); doing meditation i.e.(54%) at the maximum level. The chi square computed
between coping strategies with selected demographic variables and showed that coping strategy was
dependent on, education, monthly income and type of family of parents. But it was not dependent on
gender, religion, occupation, Number of family member and duration of child mental illness.

Keywords: Coping Strategies, Parents, Mentally Challenged Children, Special

School.

Introduction
Background: A parent is a caregiver of the offspring in
their own species. In humans, a parent is the caretaker of
a child. Parenting is a challenging process. The
crucial
Coressponding Author:
role of parents and family in caring, nurturing,
Mr. Rajesh Gaikwad
protecting and socializing young children is well
Clinical Instructor,
established across the cultures. Strong parent-child
M.Sc Nursing (Psychiatric Department)
College of Nursing Sangli, connectedness improves child academic outcomes, self
Bharati Vidyapeeth (Deemed to be) University esteem, mental health and has later protective effects of
Phone: 7020016780 reducing the likelihood of alcohol and drug use in
Email: [email protected] adolescence, high risk sexual behavior and
involvements in interpersonal
369 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 369

violence (Lezin et al., 2004)1. Parenting can influence attempting to manage the demands created by stressful
children’s social, emotion, and academic adjustment, events that are appraised as taxing or exceeding a
efforts have been made to determine factors that affect person’s resources (Lazarus &Folkman 1984). Coping is
parenting behavior. One such factor is parenting stress. an individual’s continuous effort in thoughts and actions
Parenting stress can be defined as excess anxiety and to manage specific external or internal demands
tension specifically related to the role of a parent and to appraised to be challenging and overwhelming to the
parent-child interactions (Abidin, 1995)2. individual. In addition, coping is considered highly
contextual, in that its effectiveness is determined by the
Parenting is a highly stressful job, and becoming
ability to change over time and across different
a parent of a child with a disability is one of the most
conditions (Folkman& Lazarus, 1985)6.
stressful life events that can occur. According to the
centers for disease control and prevention (CDC,
Material and Method
2015), approximately 1 in every 33 babies is born with
a birth defect, and about 1 in 6 children is born with a Non-Experimental Descriptive exploratory research
developmental disability3. A child born into family is design was used to assess the coping strategies among
usually received with joy and considered a blessing but parents of mentally challenged children at selected
when the child is handicapped and blessing is clearly special schools of Miraj, kupwad and Kolhapur
mixed. Acceptance of child with mental handicap corporation area. Sample size was 100 and sample
becomes difficult to parents and the whole family was selected by Non-probability purposive sampling
particularly when competence and achievement are very method. After clearance by the ethical review committee
much valued in modern world. A parent shows a series data collection was started a prior permission was taken
of reactions after knowing that their child is disabled. from the respective authorities and informed and written
These included shock, denial, guilt, sorrow, rejection consent was taken from the participant. Data collection
and acceptance. Questions like ‘why me?’ ‘How can it was done by using coping strategy rating scale and the
be?’ keep arising without answers4. tool was divided into two sections, section-I consist
Coping includes behavioral strategies that of demographic variables and section-II consist of
individuals use to reduce the effect or demands of stress coping strategy questionnaire. Questions were related
(Khan &Humtsoe, 2016). According to Folk man and to psychological coping, physical coping, financial
Lazarus (1984), coping efforts serves two main coping, social coping and spiritual coping and after
functions: management of the person-environment each coping strategy one open ended question was kept.
relationship and regulation of associated stressful The scoring was done on the following points 1=Never,
emotions. Lazarus (1980) defined coping as “the 2=Sometimes, 3=Always. The 25 questions
cognitive and behavioral efforts made to master, carried
tolerate, or reduce external and internal demands maximum score of 75 and minimum score of 3.
appraised as taxing or exceeding the resources of the
individual”5. Findings
Section I
Coping, defined as action-oriented and intrapsychic
efforts to manage the demands created by stressful Table-1, shows Frequency and Percentage
events, is coming to be recognized both for its significant distribution of Demographic variables like Age, Gender,
impact on stress-related mental and physical health Education and Occupation Monthly income of family,
outcomes and for its intervention potential. Stress is a Type of family, Number of family members, Family
negative experience, accompanied by predictable history of mental illness and Duration of child mental
emotional, biochemical, physiological, cognitive, and illness of parents with mentally challenged children at
behavioral accommodations (Baum 1999). Coping is the selected special schools in terms of frequency and
process of percentage.
Section II-Assessment of Coping Strategies among Parents
Table 1: Assessment of the psychological coping strategies among parents
(N = 100)
Sr. No. Coping Strategies Never Sometimes Always
Percen Percent-
A. Psychological Coping N Percent- Age N N
T-Age Age
1. Seeking guidance From relatives. 29 29.00 48 48.00 23 23.00
2. Watching TV or go for movie with the Family. 12 12.00 54 54.00 34 34.00
3. Trying to see the Positive side of the situation. 4 4.00 48 48.00 48 48.00
4. Seeking professional Counseling. 9 9.00 44 44.00 47 47.00
5. Believe that I can Handle my own problem. 8 8.00 49 49.00 43 43.00

Interpretation: In psychological coping strategy, maximum number of parents are using watching TV or going for
film with family members i.e. (54%).
Table 2: Assessment of the Physical coping strategies among parents
(N = 100)
Sr. No. Coping Strategies Never Sometimes Always
B. Physical Coping N Percent- Age N Percent- Age N Percent- Age
1. Taking help from Somebody. 6 6.00 48 48.00 46 46.00
2. Taking rest or Sleep intermittently. 1 1.00 49 49.00 50 50.00
3. Eating healthy Diet. 4 4.00 52 52.00 44 44.00
4. Making plan of Action. 7 7.00 48 48.00 45 45.00
5. Trying to found Several alternatives. 3 3.00 44 44.00 53 53.00

Tinterpretation: In physical coping strategy, maximum number of parents were using, trying to found
several
alternatives i.e. (53%).
Table 3: Assessment of the financial coping strategies among parents
(N = 100)
Sr. No. Coping Strategies Never Sometimes Always
C. Financial Coping N Percentage N Percentage N Percentage
1 Working hard to Solve problem. 5 5.00 50 50.00 45 45.00
2 Reducing Household budget. 3 3.00 48 48.00 51 49.00
3 Talking with the Experts. 1 1.00 50 50.00 49 49.00
4 Taking help from Friends and relatives. 3 3.00 49 49.00 48 48.00
5 Taking help from NGO‟s. 0 0.00 49 49.00 49 51.00

Interpretation: In financial coping strategy, maximum number of parents where using reducing household budget
i.e. (51%).
Table4: Assessment of the Social coping strategies among parents
(N = 100)
Sr.
Coping Strategies Never Sometimes Always
No.
D. Social Coping N Percent-Age N Percent-Age N Percent- Age
1. Sharing difficulties 1 1.00 49 49.00 55 50.00
2. Seeking encouragement and support 6 6.00 49 49.00 40 45.00
3. Seeking Information and advice. 3 3.00 50 50.00 47 47.00
4. Seeking assistance from community Agencies. 0 0.00 48 48.00 52 52.00
5. Involving in Social activities. 1 1.00 44 44.00 55 55.00

Interpretation: In social coping strategy, maximum numbers of parents were using sharing difficulties with friends
and relatives i.e. (55%)
Table 5: Assessment of the Spiritual coping strategies among parents
(N = 100)
Sr. No. Coping Strategies Never Sometimes Always
E. Spiritual Coping N Percent- Age N Percent- Age N Percent- Age
1. Participating in Religious Activities. 3 3.00 49 49.00 48 48.00
2. Doing Meditation 2 2.00 46 46.00 54 52.00
3. Hope That God Will Make Magic. 2 2.00 50 50.00 48 48.00
4. Seeking Advice from a Spiritual Leader. 1 1.00 46 46.00 53 53.00
5. Having Faith in God or Higher Power. 3 3.00 45 45.00 52 52.00
Interpretation: In spiritual coping strategy, maximum mental Illness was no significant association of these
numbers of parents were using doing meditation i.e. demographic variables with the coping strategies among
(54%). parents of mentally challenged children.
Section III: Table- 7: Deals with analysis of data Conflict of Interest: The author declares that they have
related to the association between coping strategies with no any conflict of interest.
selected demographic variables.
Source of Funding: The whole research funding
Significant Association: Demographic variables like age, was
education, monthly income and type of family, the p done by the researcher by self.
value of the association test with coping strategies was
less than Ethical Clearance: A research proposal approved by
0.05. Concludes that, there was significant association of Institutional Ethical Committee (IEC), meeting was
these demographic variables with the coping strategies held in Bharati Vidyapeeth (Deemed to be University)
among parents of mentally challenged children. College of Nursing, Sangli. The permission for pilot and
main study were obtained from selected special schools
Not Significant Association: Demographic variables like of Kupwad Kolhapur corporation area to conduct study
gender, religion, occupation, Number of family members after IEC.
and Duration of child mental Illness the p value of the
association test with coping strategies was more than
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of these demographic variables with the coping strategies 1. Narmada Hidangmyum and Pushpa B. Khadi,
among parents of mentally challenged children. Parenting stress of normal and mentally
challenged children, Karnataka J. Agric,
Conclusion May,2012, Sci.,25 (2). Page no-256-258.
2. Rishi Panday, Nazish Fatima, Quality of life
The study concluded that the coping strategies
among parents of mentally challenged children,
used by the parents of mentally challenged children are
The International Journal of Indian Psychology,
watching TV or going for film with family members
April-June,2016; Volume 3, Issue 3, No. 11, Page
i.e. (54%); trying to found several alternatives i.e.
no- 152-157. http://www.ijip.in
(53%); reducing household budget i.e. (51%); sharing
difficulties with friends and relatives i.e. (55%); doing 3. Mohd. Faijullah, Mohd. Ansar Alam, coping
meditation i.e. (54%) at the maximum level. trends of parents having children with
developmental disabilities: a literature review,
And the Association depicts that variables like age, European Journal of Special Education Research,
education, monthly income and type of family was 2016, Volume 1/ Issue 3, Page no- 39-45.
significant association of these demographic variables www.oapub.org/edu
with the coping strategies among parents of mentally
challenged children. 4. Bagher Ghobari Bonabet al; Effect of coping
strategies on stress of parents with Intellectual
And variables like gender, religion, occupation, Disabilities Children, Asian Education Studies,
Number of family members and Duration of child July 2017, Vol. 2, No.3; Page no- 11-12. https://
doi.org/10.20849/aes.v2i3.187
5. Shelley E. Taylor and Annette L. Stanton 11. Bager Ghobar Bonab et al; Effect of Coping
Coping resources, Coping Processes, and Mental Strategies on stress of parents with Intellectual
Health, Annual Review of Clinical Psychology, disabled children, Asian Education Studies,
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http://clinpsy.annualreviews.org https://10.20849/aes.v2i3.187
6. Leonard Abbeduto et al; Psychological well- 12. Shahzadi Malhotra et al; Quality of life of parents
being and coping in mothers of youths with having children with developmental disabilities,
Autism, Down syndrome, or Fragile X Syndrome, Delhi psychiatric journal, April 2012, Vol.15,
American Journal on Mental Retardation, May No.1; Page no-171-177.
2004, Volume 109, Number 3, Page no 237-254.
13. Ritu Raj Gogoi et al; Anxiety, depression, and
7. Upadhyaya GR, Havalappanavar NB. Coping in Quality of life in mothers of children with
parents of mentally challenged children. Journal intellectual disability, open journal of
of Indian Academy of applied Psychology, 2008 psychiatry
Jul; 34(2), Page no-221-225. & allied science, 20th November 2016. www.
8. Narmada Hidangmayum and Pushpa.B. Khadi, ojpas.com
Parenting stress of normal and mentally 14. M. B. Olsson and C. P. Hwang, Depression in
challenged children, Karnataka j. Agri Sci (2); mothers and fathers of children with intellectual
May 2012, Page no-256-259. disability, journal of intellectual Disability
9. Venkatesh Kumar G, Psychological Stress Research, December 2001, Volume 45, Part 6,
and Coping Strategies of parents of mentally Page no-535-543.
challenged children, Journal of the Indian 15. Nosheen Ramzan, Khaula Minhas, Anxiety
Academy of Applied Psychology, July 2018, vol- and depression in mothers of disabled and non-
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Mechanism among parents of Intellectual 16. Ajit Deshpande, Sanjay Kubde et al; A study of
Disabled children, Journal of Advance Academic stress in mothers of mentally challenged students,
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DOI Number: 10.5958/0976-5506.2019.01597.3

Effectivness of Curry Leaves Powder on Blood Sugar Level

among Diabetic Patients

Kunal V Jadhav1, Basavant Dhudum2

1
Final Year M.Sc Nursing Student, 2Assistant Professor, Bharati Vidyapeeth (Deemed To
Be) University College of Nursing, Sangli

ABSTRACT
“A study to assess the effect of curry leaves powder on blood sugar level among diabetic patients in
selected
areas of Sangli Miraj Kupwad Corporation.”
The Objectives of the Study:
1. To assess the fasting blood sugar level and post prandial blood sugar level before administration of curry
leaves powder among diabetic patients.
2. To assess the fasting blood sugar level and post prandial blood sugar level after administration of curry
leaves powder among diabetic patients.
Material and Method: An experimental Research Design was adopted for this study. The study was
conducted in selected areas of Sangli Miraj kupwad Corporation. Windenbach’s prescriptive theory is
used in this study. Sample size was 60 where, 30 samples were included in control group and 30 samples
were included in experimental group. Samples were selected using non probability convenient sampling
technique.12 gm of Curry leaves powder was administered to the client per day for 20 days. The data
collection was done using Glucometer which was noted down in blood level accessing chart. The data was
analyzed using descriptive and inferential statistics
Result with Conclusion: In this study 56.67% of clients were between 51 and above age group in
experimental group. There were equal no of male and female client in both the group. Experimental and
control group revealed that average fasting blood sugar level was 157. 47 with SD 9.54 and in control
group were 151.37 with SD 9.10. By using paired T test comparison of average fasting blood sugar and
postprandial blood sugar level of first day and 20th day was done. The calculated P value was 0.00 which
stated that there was significant difference in average fasting blood sugar level and postprandial blood sugar
level at 5% level of significance.
As there was no significant difference in fasting blood sugar level of control group due to extraneous
variables there is a significant reduction in blood sugar level in experimental group compared to control
group. The P value is > 0.05 which indicate that there was significant difference after the administration of
curry leaves powder among diabetic patient hence curry leaves powder is helpful for reducing blood sugar
level among diabetic patients.

Keywords: curry leave, diabetes, insulin, blood sugar, blood

vessels
Introduction
Corresponding Author: Diabetes’s metabolic disease and chronic disease
Kunal V Jadhav that increase blood glucose level over a long period. If
Final Year M.Sc Nursing Student, proper treatment is not provided to the diabetic client
Bharati Vidyapeeth (Deemed to Be) University they may suffer from various complication like chronic
College of Nursing, Sangli-416414 foot ulcer heart disease stroke and serious long term
Email: [email protected] complications1.Diabetic mellitus is a chronic disease
374 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 374

caused due to lack of production of insulin to pancreas or unsuccessfulness of insulin produced so the increase
blood sugar level in the body system particularly in nerves and blood vessels2. According to the data of International
diabetes Federation atlas in India estimated 69.2 million are diabetic clients. WHO suggested that 30.3% people are
diabetic patient Diabetes is rapid gaining the status of potential epidemic in India with high rate of 62 million
diabetic individuals currently diagnosed with this disease3.Day to day care of diabetic client like maintaining
physical activity food management Keeping weight and tension under control, checking the blood Glucose level,
Recording oral medication and insulin. Diabetic patient uses many alternative therapies to reduce the blood sugar
level4.Diabetes to curry leaves loaded with antioxidants like beta acetone and vitamin c curry leaves have the ability
to keep most diseases at bay. Especially type 2 diabetes herbal remedies for manually diabetes and how to use it to
stable blood sugar level.

Material and Method

A present study was conducted using Quantitative research approach. The research design selected was Pre test
post test case control group design. The conceptual frame work was based on Ernestine Wiedenbach’s prescriptive
theory. Non probability, convenient sampling method was used. Validity was done from 20 experts. Type II diabetic
clients were selected for the study from selected areas of Sangli, Miraj, and Kupwad Corporation. Sample size was
60, in which 30 were included in experimental group and 30 were included in control group. Proposal with tool
presented in front of ethical committee for permission. Curry leaves in the form of powder was provided in sachets
6 gm each twice a day for 20 days. 6 gm before the lunch with sips of water and 6 gm before dinner with sips of
water. Curry leaves powder was administered to the diabetic patients for 20 days. Fasting blood glucose level and
post prandial glucose level was checked on 1st day with the help of Glucometer On 10th and 20th day fasting blood
glucose level was checked in the morning on empty stomach and post prandial blood sugar level was checked 2 hrs
after the lunch. Data was recorded on assessment chart.

Findings

Section I

Table 1: Frequency and percentage distribution of diabetic patients according to demographic variables
n = 60

Experimental Control
Sr. No. Variable Groups
Frequency Percentage Frequency Percentage
41-50 13 43.33 15 50.00
1. Age
51 & Above 17 56.67 15 50.00
Male 15 50.00 15 50.00
2. Sex
Female 15 50.00 15 50.00
0-5 14 46.67 20 66.67
Duration of
3. 6-10 10 33.33 7 23.33
disease
11-15 6 20.00 3 10.00
Any other Yes 16 53.33 17 56.67
4.
illness No 14 46.67 13 43.33
Arthritis 5 31.25 6 35.29
5. Illness Obesity 7 43.75 6 35.29
Respiratory Disease 4 25.00 5 29.41
Section II: Deals with analysis of data related to assessment of blood sugar level among diabetic patients
experimental
and control groups.
n = 30 + n = 30

Figure 1: Assessment of blood sugar level in Experimental & Control Groups

n = 30 + n =30
Figure 2: Assessment of blood sugar level in Experimental & Control Groups

Section III: Deals with analysis of data related to the effectiveness of curry leaves powder on blood sugar
level
among diabetic patients in experimental and control groups.

Table 2: Comparison of blood sugar level among diabetic patients in experimental group
n = 30
Experimental - Paired t test
BSL F Frequency Mean S.D. t value P value
Day 1 30 157.47 9.54
5.32 0.00
Day 20 30 146.77 12.94
BSL PP Frequency Mean S.D. t value P value
Day 1 30 212.40 12.84
21.4 0.00
Day 20 30 198.27 14.22
Table 3: Comparison of blood sugar level among diabetic patients in Control group
n = 30

Control-Paired t test
BSL F Frequency Mean S.D. t value P value
Day 1 30 151.37 9.10
1.37 0.18
Day 20 30 150.50 8.65
BSL PP Frequency Mean S.D. t value P value
Day 1 30 211.17 9.87
3.87 0.001
Day 20 30 208.63 9.72

Discussion Average post prandial blood sugar level of

SECTION I experimental group was 198.27 with SD 14.22 and
in
Fig no 2: On day 20 average fasting blood sugar level
1. Age: In experimental group, most of them 56.67%
of experimental group was 146.77 with SD 12.94 and in
were between 51yrs and above
control group it was 150.5 with SD of 8.65.
In control group, 50% were between 51yrs
and
above
2. Gender: In experimental group, 50% were female
patients and 50% male patients.
In control group also, 50% were female
patients
and 50% male patients.
3. Duration of disease: In experimental group, most
of them 46.67% had the diabetes in group 0-5
years.
In control group, most of them 66.67% had
the
diabetes in group 0-5 years.
4. Any other illness: In experimental group, to the
question have any other illness other than diabetes
most of them 53.33% were answered yes. People
had other illness like respiratory disease, arthritis
and obesity.

Section II

Fig no 1: Assessment of blood sugar level in

Experimental & Control Groups revealed that on day 1
average fasting blood sugar level of experimental group
was 157.47 with SD 9.54. And in control group it
was
151.37 with SD of 9.10.

Average post prandial blood sugar level of

experimental group was 212.4 with SD 12.84. And in
control group it was 211.17 with SD of 9.87.
control group it was 208.63 with SD of 9.72.

Section III

Experimental Group

Fasting BSL: The comparison of the average fasting

BSL of the day 1 and day 20 of experimental group
was done by the paired t test. The day 1 average fasting
BSL was 157.47 with standard deviation of 9.54 the
day 20 averages fasting BSL was 146.77 with standard
deviation of 12.94. The test statistics value of the paired
t test was 5.32 with p value 0.00. Shows that there was
significant difference in the average fasting BSL at 5%
level of significance

Post Prandial BSL: The comparison of the Post

Prandial BSL of the day 1 and day 20 of experimental
group was done by the paired t test. The day 1 average
Post Prandial BSL was 212.40 with standard deviation of
12.84. The day 20 average post Prandial BSL was
198.27 with standard deviation of 14.22. The test
statistics value of the paired t test was 21.4 with p value
0.00. Shows that there was significant difference in the
average post Prandial BSL at 5% level of significance

Control Group

Fasting BSL: The comparison of the average fasting

BSL of the day 1 and day 20 of control group was done
by the paired t test. The day 1 average fasting BSL was
151.37 with standard deviation of 9.10. The day 20
average fasting BSL was 150.50 with standard deviation
of 8.65. The test statistics value of the paired t test was
1.37 with p value 0.18.The p value more than 0.05,
concludes that there was no significant difference in the
average fasting BSL at 5% level of significance.
Various extraneous variables were responsible for 1. Silva JAD, Souza ECF, Echazú Böschemeier
the findings to be not significant such as diet pattern, AG, Costa CCMD, Bezerra HS, Feitosa
type of work, exercise etc. EELC.

Post Prandial BSL: The comparison of the Post

Prandial BSL of the day 1 and day 20 of control group
was done by the paired t test. The day 1 average Post
Prandial BSL was 211.17 with standard deviation of
9.87. The day 20 average post Prandial BSL was 208.63
with standard deviation of 9.72. The test statistics value
of the paired t test was 3.87 with p value 0.001. The p
value > 0.05, stated that there was significant difference
in the average post Prandial BSL at 5% level of
significance.

Conclusion

The study revealed that the p value was > 0.05,

stated that there was significant difference in the average
fasting and post Prandial BSL at 5% level of
significance. Effect of curry leaves powder was seen
after administrating to client; it reduced blood sugar
level after specific time span. Curry leaves powder is
helpful for the diabetic clients to reduce blood sugar
level without any side effects as curry leaves are easily
available and are very cheaper to buy. It can be utilized
for medicinal use as well as to reduce blood sugar level.
Cardiac patients are not recommended to consume curry
leaves powder.

Conflict of Interest: Nil

Source of Funding: Self

Ethical Clearance: Proposal of research with the data

collection tool was presented in the front of research
committee for approval. Prior permission from
corporator of the area was taken. Informed written
consent from each participant was taken, which included
name, number, organization, time duration of
participation, termination of participation, purpose of the
study, incentives, benefits, and where it was promised
that there will be no risk to the clients. Principle of
confidentiality was attained by giving code number to
data collection tool. The received information also kept
confidential. Ethical clearance is done with the
committee members Dr. Sripriya and Dr. Nilima Bhore
Mam.

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B. Type 2 diabetes mellitus: a review of current
trends. Oman medical journal, 27(4), 269-73.
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11. Khwaja S. Zafar, Tony Pious, Prem S. Singh,
Rajesh K. Gautam, Sudhir K. Et. Al Prevalence
of metabolic syndrome in a rural population-
Western Uttar Pradesh, India Int J Res Med 17. Anjana RM, Deepa M, Pradeepa R, Mahanta J,
Sci. Narain K, Das HK, Adhikari P, Rao PV, Saboo
2017 May;5(5):2223-2228 B, Kumar A et al., Prevalence of diabetes and
12. Gomathi, K N Effectiveness of curry leaves in prediabetes in 15 states of India, Lancet Diabetes
decreasing blood glucose among type II diabetes Endocrinol. 2017 Aug; 5(8):585-596. Doi:
clients in selected rural areas at Medavakkam, 10.1016/ S2213-8587(17)30174-2. Epub 2017 Jun
Chennai. Masters thesis, College of Nursing, 7.
Madras Medical College, Chennai. (2016) 18. Maria Isabella Creatore, Rahim Moineddin, et al.,
13. Chinn, P., & Jacobs, M. (Eds.). Theory and Age- and sex-related prevalence of diabetes mellitus.
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DOI Number: 10.5958/0976-5506.2019.01598.5

A Framework Analysing Patient Adherence Level in

Cardiovascular Disease in Delhi-NCR Region

Navjot Kaur1, Supriti Agrawal2, Hemendra Gautam3

1
Research Scholar, Amity Institute of Pharmacy, 2Assistant Professor, Amity Business School,
Amity
University, Noida (UP); Director, Future Institute of Pharmacy, Bareilly
3

(UP)

ABSTRACT
The deficit in the patient adherence level is considered to be the most problematic factor in chronic
diseases. The cross-sectional study on cardiovascular disease related patients was conducted in hospitals of
Delhi- NCR region in the month of July 2018- August 2018. The total respondents taken were about 144
and were selected from cardiovascular diseases such as coronary artery disease, heart attack, abnormal heart
beat, heart valve disease, congenital heart disease, aortic disease, vascular disease etc. The respondents
were from various age groups and the results were concluded on the basis of the treatment and
medications. The reliability of Morisky Medication Adherence Scale-8 was upto 0.78 which is
considered to be good and on the basis of adherence scale category, the widely held of patients were
categorized under medium adherence level. The chief factors which seems to be responsible for low
adherence level were- monotonous life schedule, long waiting times in hospitals, irregular visits, high cost
of treatment, forgetfulness etc.

Keywords: WHO, adherence, cardiovascular diseases,

MMAS
Introduction The patients used to invest a good amount of cost
for the chronic diseases for detection, screening and
The boom of chronic diseases in the previous
treatment. In between year 2008-2015 in India,
years has totally changed the attribute in the field
about
of medical science. It has been reported in one of the
1.3% of total GDP has invested in public health and
article in Times of India, 2016, that over 20% of Indian
that further increased up to 1.4% in 2016-2017 which
population is suffering from chronic diseases [1]. In the
is still less than the world average percentage that is 6%
latest report of 2018 by WHO, the chronic diseases or [3]
. Also, the National Health Policy in 2017 proposed
non-communicable diseases enlisted as heart ailments, that this expenditure will increase up to 2.5% of GDP
cancer, respiratory diseases, diabetes etc. kill about 41 by 2025 [3].
million people globally every year [2]. Also, in this report
it has been mentioned that the cardiovascular diseases The poor medication adherence level is one of
accounted for the highest death rate among the patients the major causes that highly affect the patients in
that ranges up to 17.9 million people every year, chased many ways. Poor medication adherence causes many
by cancer patients up to 9 million, respiratory diseases complications towards treatment process, disease
up to 3.9 million and diabetes patients up to 1.6 million. progression, disability in case of inappropriate treatment
and in some cases death of the patient [4]. In various
studies, it have shown that the non-adherence towards
diseases like hypertension, diabetes and hyperlipidemia
etc, the hospitalization rate increased, medical outcomes
Corresponding Author: get worsened and also on the whole healthcare cost
Ms. Navjot Kaur augmented [5,6].
Research Scholar, Amity Institute of Pharmacy,
Amity University, Noida -201313, (UP) Talking about the overall impact of medication
Phone: +91-7571073456 adherence by the patients, it not only improves or
Email: [email protected] reduces the cost of treatment but it also helps to improve
the clinical outcomes for particular disease. In one
of
380 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 380

the study, it has been proved that patient adherence in z Intricacy of the treatment provided
case of anti-hypertensive medications resulted in blood
z Cost of the medication is not affordable
pressure control and also shown the long-term beneficial
outcomes [6]. There are large numbers of factors that z Patient and provider relationship is badly chosen
are indulged in the field of medical science to improve
z Lack of belief in the benefit of the treatment
the patient adherence level. In the field of healthcare
sector, the healthcare providers, government policies, z Side-effects from the treatment taken
third party players, online services and other related z Insufficient follow up by the healthcare provider
disease management programs helped out the patients to
improve the adherence level on large scale [7,8]. In such way, we can analyse that how the patient
adherence level towards their medications and treatment
For the successful treatment and desired results of is important for chronic type of diseases. This adherence
any medication, the main thing is the patient’s level helps the patients to recover from disease in a
compliance i.e. the patient should follow their better way.
medications properly. According to WHO, in the
meeting conducted on adherence in June 2001,
Objectives
adherence is defined as “the extent to which the
patients follow medical instructions” [9]. It is very The study is done to understand the adherence level
essential for the patients to take their medications, of cardiovascular patients and it focuses on following
with proper diet including lifestyle changes and agreeing objectives-
the recommendations of healthcare providers. The
adherence includes three basic steps i.e. initiation of 1. To study the factors affecting patient adherence
the treatment, implementation of the prescribed towards medications and treatment.
treatment and discontinuation of the pharmacotherapy 2. To understand the patient perspective towards low
[10]
. The medication adherence level has its own medication adherence
benefit in the field of patient wellness to improve the
diseased condition and course therapies and for 3. To develop a holistic framework for better
implementing this it is important to follow the basic adherence level.
steps in adherence.
Methodology
It is very well said that adherence helps to reduce
the whole cost at the time of treatment. In a literature, it The sample size of about 144 patients were selected
has been mentioned that if medication lessen with time suffering from cardiovascular diseases such as- coronary
then in future the hospitalization rate and total cost of artery disease, heart attack, abnormal heart beat, heart
care increases [11, 12]. Thus, it is very essential for the valve disease, congenital heart disease, aortic disease,
patients to stick with their treatment procedure so as to vascular disease etc. The patients who were suffering
get desired results. Adherence is like the capability or from above cardiovascular diseases were included in the
eagerness of the patients to stick with the therapeutic study and also the communication was done in hindi and
course of therapy [13]. When the patient doesn’t stick to english language. Face-to-face interview was conducted
their medications as prescribed by the healthcare in various hospitals of Delhi-NCR region. The cross-
provider then it is known as non-adherence or non- sectional study was conducted out in various hospitals
compliance. The non- adherence of medications can be of Delhi-NCR region from the month of July 2018- Aug
due to many reasons such as- taking incorrect dose, 2018 and the hospitals provided the OPD patients
delaying in treatment, not following doctor’s for
instructions properly etc. In one of the research, the the survey.
non-adherence is said to be multi factorial [14] as there are
many reasons due to which the patients don’t take their The respondents were taken from various age
medications properly and some of the reasons are as groups and also on the basis of the treatment and
follows- medications for the disease. The patients were asked
for the level of agreement on statements of Morisky
z Psychological reasons
Medication adherence scale (MMAS-8). For each
z Missed the upcoming appointments with statement,
physicians
they had to anchor Yes or No with the score of 1 or 0 diseases. From the table 1, it is clear by the value
respectively. Also, some additional questions were asked 0.78
about the type of hospitals, number of medicines in a that the statements showed good reliability.
day, family type, occupation etc. Table
2 shows the total item statistics for each statement
Results and Discussion and which have also shown good reliability for the
statements. Talking about the MMAS and its adherence
Pre-testing of the questionnaire: The pre-testing of level scale, the MMAS category of high adherence,
the questionnaire was done by taking 35 respondents medium adherence and low adherence was calculated
erratically and they were requested to give the remarks in which the values were 21, 110 and 13 respectively.
related to language and clarity of the questionnaire. The score of 0 is categorized as high adherence,
On the basis of the suggestions the changes were score
done accordingly for cleanness and specificity of the 1-2 is categorized as medium adherence and score 3-8
statements. is categorized as low adherence. The widely held of
patients were under medium adherence level suggesting
Reliability of the survey: The data collection also
that patients should focus on improving this adherence
needed reliability analysis for assessing the accuracy in
level towards medications and treatments
the survey process so for this Cronbach’s alpha was the
result showed the reliability of 0.78. Table 1 showed the The graph 1 below showed that the majority of the
value of Cronbach’s alpha for the statements of Morisky patients started their treatment after few days when they
Medication Adherence Scale to measure the medication were diagnosed of disease which shows that patients
adherence level of patients suffering from cardiovascular are aware about their health. The patients are now
emphasizing on their health issues and also they use to
have regular discussions with their families or friends.
Table 1: Reliability Statistics
Cronbach’s Alpha Cronbach’s Alpha Based on Standardized Items N of Items
.780 .821 8

Table 2: Frequency distribution showing demographics of respondents

Category No. of people Percentage Cumulative percentage
20-30 years 30 20.8 20.8
30-40 years 52 36.1 56.9
40-50 years 29 20.1 77.1
Age in years
50-60 years 12 8.3 85.4
>60 years 21 14.6 100.0
Total 144 100.0
Male 78 54.2 54.2
Gender Female 66 45.8 100.0
Total 144 100.0
Illiterate 23 16.0 16.0
Upto 12th standard 56 38.9 54.9
Graduate 35 24.3 79.2
Education
Post graduate 28 19.4 98.6
Others 2 1.4 100.0
Total 144 100.0
Business 31 21.5 21.5
Home maker 44 30.6 52.1
Occupation Professional 60 41.7 93.8
Retired 9 6.2 100.0
Total 144 100.0
Conted…
Single 21 14.6 14.6
Married 90 62.5 77.1
Divorced 16 11.1 88.2
Marital Status
Widowed 17 11.8 0
Others 0 0 100.0
Total 144 100.0
Nuclear 81 56.2 56.2
Family Joint 63 43.8 100.0
Total 144 100.0

Graph 1: Showing the time of treatment when started

Conclusion On the support of improving patient adherence
level, there are various factors that may help patients
The study identifies that now-a-days patients are not
to stick towards medications such as- regular patient
more adherent towards their medications and treatment
due to large number of factors. The inappropriate counselling, various campaigns by the hospitals or
behaviour towards non-adherence causes patients to have clinics, digital reminders for the patients provided by
long and sometimes serious illness. The results from the medical healthcare professional and family support.
MMAS-8 also showed that majority of the patients are Thus, it is very essential for the patients to stick to the
low adherent towards their treatment. The major treatment and medications for better improvement of the
objective of the research was to analyse the factors that health.
affect patient adherence level towards medication and
Ethical Clearance: For this study there was no
treatment and some of the factors were like- monotonous
life schedule, long waiting times in hospitals, irregular requirement for ethical clearance certificate.
visits to doctors, severe symptoms during medications,
Source of Funding: The source of funding was self.
interaction with healthcare professionals, family
support, forgetfulness, high cost of medications and Conflict of Interest: Nil
treatment etc.
REFERENCES management interventions for chronic conditions:
1. Over 20 pc of Indians suffers from a meta-review, Worldviews Evid Based Nurs.,
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2. WHO report, 2018 action, WHO, 2003; 18.

3. Rao N., Who is paying for India’s healthcare?, 10. B. Vrijens, S. de Geest, D. A. Hughes et al., A
The Wire, April 14. new taxonomy for describing and defining
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4. Hughes OA, Bagust A, Haycox A, Walley T, Clinical Pharmacology, 2012; 73(5): 691–705.
The impact of non-compliance on the cost-
effectiveness of pharmaceuticals: a review of the 11. American Diabetes Association. Direct and
literature, Health Econ., 2001; 10: 601-615. indirect costs of diabetes in the United States.
Available at: www.diabetes.org/diabetes-
5. Pladevall M, Williams LK, Potts LA. et al., statistics/cost-of-diabetes-inus. jsp. Accessed on
Clinical outcomes and adherence to medications December 2018.
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12. Choo PW, Rand CS, Inui TS, et al., Validation
Diabetes care, 2004; 27(12): 2800-2805.
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6. DiMatteo MR, Giordani PJ, Leeper HS, Croghan and pill counts with electronic monitoring of
TW, Patient adherence and medical treatment adherence to antihypertensive therapy, Med Care,
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13. Inkster ME, Donnan PT, MacDonald TM, et al,
794-811.
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7. Ratanawongsa N, Karter A, Parker MM, et al., association with patient and practice factors, J
Communication and medication adherence: the Hum Hypertens, 2006 20:295–7.
diabetes study of Northern California, JAMA
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Intern Med., 2013; 173(3): 210-218.
medication, N Engl J Med 2005; 353:487-497
8. Jones KR, Lekhak N, Kaewluang N, Using mobile
phones and short message service to deliver self-
DOI Number: 10.5958/0976-5506.2019.01599.7

A Study to Assess the Effect of Pineapple Extract on

Episiotomy Wound Healing among Postnatal Mothers in
Selected Hospitals of Sangli, Miraj and Kupwad Corporation
Area

Sindhu R.Gaikwad1, Nilima R. Bhore2

1
M.Sc 2nd Year Nursing, 2Dean Faculty of Nursing & Principal, Bharati Vidyapeeth
(Deemed to be University) College of Nursing Sangli

ABSTRACT
Pregnancy1 is a beautiful and natural condition. Nine transformative months full of excitement, planning
and peering at the awesome unfolding of life. After delivery, Episiotomy is one of the most important
areas of concern. The perineum is highly susceptible to infection due to different secretions like vaginal
discharges, feces and urine. Episiotomy wound requires a proper intervention which could otherwise be self
- limiting due to high vascularity of perineal area. If not taken care, episiotomy wound may lead to
immediate complications like infection, dehiscence or remote complications like dyspareunia, scar
endometriosis or chances of perineal lacerations in subsequent labour. Extracts from pineapple helps to
improve healing time and would aid outcome. Pineapple is easily available and doesn’t cost much. It is
crucial to discover the opportunity of using pineapple to enhance episiotomy wound healing.
Aim: To assess the condition of episiotomy wound and assess the effect of pineapple extract on episiotomy
wound healing.
Keywords: Post natal mother, episiotomy, wound healing, pineapple
extract.

Introduction Bharati Vidyapeeth (Deemed to be University)

College of Nursing, Sangli
Pregnancy has some complications2 which needs Email:[email protected]
specific care. Pregnancy is split into 3 trimesters.3 in
women ages 15-49years the number of pregnancies
is 144.7 per 1000 women. About 43% were planned
pregnancies, 9%miscarriage from planned
pregnancies,
11%were unintended birth, and 33% induced
abortion,
5% miscarriage from unintended pregnancy4.

Vaginal delivery5 is the most common way of

childbirth. Postpartum period6 is the time of adjustment
after child birth when anatomical and physiological
changes of consumption are reversed to an almost
pre

Corresponding Author:
Dr. Mrs.Nilima R. Bhore
Dean Faculty of Nursing & Principal
pregnancy level. Early discharge is given to mother and
newborn within 48 hours of birth.7 Midwifery care8 is
strengthened through the world; by monitoring physical,
psychological and social well-being of mother
throughout the childbearing cycle, providing
individualised education to mother, counselling and
prenatal care, and minimising technological
interventions, identifying and referring women who
require obstetrical attention.

Episiotomy9 performed routinely during childbirth

to prevent tears and trauma during delivery. Normal
wound healing includes homeostasis, inflammation,
proliferation and remodeling...Care of postnatal mothers
with episiotomy can be done economically if the nurse
is competent with skills to provide various remedial
measures for wound healing. Pineapple is used for
medical purposes since decades and it also used as a
digestive aid and a remedy for skin disorders 10. From
pineapple stem and fruits.11 a crude, aqueous Bromelain
extract is derived. Bromelain is efficient in decreasing
inflammation, bruising and pain in women having
episiotomy. It helps in faster wound healing.
385 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 385

Objectives: purposive sampling method 60 samples were selected.

1. To assess the condition of episiotomy wound. A standardized REEDA SCALE was used to evaluate
the impact of pineapple extract on episiotomy wound
2. To assess the effect of pineapple extract healing. “Widenbach prescriptive theory” was adopted
on
as a theoretical base for framework of this study.
episiotomy wound healing.
Analysis was done using frequency and percentage
distribution and paired’ test.
Materials and Method
Hypothesis:
A quasi-experimental two group pre-test post-test
design was conducted to assess effect of pineapple H0 : There is no change in episiotomy wound healing
extract on episiotomy wound healing among postnatal after application of pineapple extract in experimental
mothers in selected hospitals of Sangli, Miraj and group.
Kupwad corporation area.” By using non-probability

Findings

Section I: Frequency and percentage distribution of demographic variables

Table 1: frequency and percentage distribution based on age, parity, education, and dietary pattern
n = 30 + n = 30
Experimental Group Control Group
Variables
Frequency Percentage Frequency Percentage
19-23 15 50% 14 46.67%
Age in years 24-28 10 33.33% 13 43.33%
29-33 5 16.67% 3 10%
1 17 56.67% 14 46.67%
Parity 2 12 40% 15 50%
3 1 3.33% 1 3.33%
Under graduates 20 66.67% 25 83.33%
Education Graduates 9 30% 5 16.67%
Post graduates 1 3.33% 0 -
Vegetarian 12 40% 12 40%
Dietary pattern
Mixed 18 60% 18 60%

Above table shows that, maximum number of samples 50% were between 19-23 years of age group, 56.67%
were with parity 1, 66.67% were undergraduates and 60% were taking mix diet in experimental group, whereas
maximum numbers of samples 46.67% were between 19-23 years of age group, 50% with parity 2, 83.33% were
undergraduates and 60% were vegetarian in control group.

Table 2: Frequency and percentage distribution based on weight, family income, occupation and type of
episiotomy n =
30 + n = 30

Experimental Control
Variables
Frequency Percentage Frequency Percentage
46-55 12 40% 12 40%
Weight in kg 56-65 12 40% 18 60%
66-75 6 20% 0 0%
Conted…
<10,000 5 16.67% 7 23.33%
Family Income 11,000-20,000 15 50% 16 53.33%
in Rs. 21,000-30,000 7 23.33% 6 20%
31,000-40,000 3 10% 1 3.33%
Housewife 24 80% 26 86.67%
Occupation
Service 6 20% 4 13.33%
Medio-lateral 30 100% 30 100%
Type of
Lateral 0 0% 0 0%
Episiotomy
Medial 0 0% 0 0%

Above table shows that maximum numbers of samples i.e. 40% of the mothers were in 46-55 kg weight group,
50% were in 11000-20000 family income groups, 80% were housewives and 100% mother had Medio lateral type
of episiotomy in experimental group whereas 60% mothers were in 56-65 kg, weight group, 53.33% were in 11000-
20000 family income group, 86.67% were housewives and 100% mother had Medio lateral type of
episiotomy in
control group.

Section II

Table 3: Pre/post observation of episiotomy wound healing parameters in control group

n = 30

Sr. Pre Post

Parameters t value p value
No Mean S.D. Mean S.D.
1. REDNESS 3.00 0.00 1.60 0.49 15.39 0.00
2. EDEMA 3.00 0.00 1.96 0.31 17.70 0.00
3. ECMOSIS 2.70 0.46 1.33 0.47 11.19 0.00
4. DRAINAGE 2.60 0.47 0.96 0.41 17.40 0.00
5. APPROXIMATION 3.00 0.00 1.93 0.25 23.03 0.00

Above table shows that pre observation episiotomy wound healing parameters scores of redness, edema,
ecchymosis, discharge, approximation in control group are 3, 3, 2.70, and 2.60,3 respectively where as post
observation scores are 1.60, 1.96, 1.33, 0.96, and 1.93 respectively.
Table 4: pre/post observation of episiotomy wound healing parameters in experimental group
n = 30

Sr. Pre Post

Parameters t value p value
No. Mean S.D. Mean S.D.
1. REDNESS 3.00 0.00 1.10 0.30 34.11 0.00
2. EDEMA 2.96 0.18 1.16 0.37 24.23 0.00
3. ECMOSIS 2.70 0.46 0.90 0.40 16.16 0.00
4. DRAINAGE 2.66 0.47 0.36 0.49 21.14 0.00
5. APPROXIMATION 3.00 0.00 1.60 0.49 15.39 0.00

Above table shows that pre observation episiotomy wound healing parameters scores of redness, edema,
ecchymosis, discharge, approximation in experimental group are 3, 2.96, 2.70, 2.66, and 3 respectively where as
post observation scores are 1.10, 1.16, 0.90, 0.36, and 1.60 respectively.
Table 5: Mean scores and s.d. of episiotomy wound healing parameters in experimental and control groups
n = 30 + n = 30

Sr. Experimental Group Control Group

Parameters t value p value
No. Mean S.D. Mean S.D.
1. REDNESS 1.10 0.30 1.60 0.49 4.69 0.00
2. EDEMA 1.16 0.37 1.96 0.32 8.83 0.00
3. ECCHYMOSIS 0.90 0.40 1.33 0.47 3.79 0.00
4. DRAINAGE 0.36 0.49 0.96 0.41 5.12 0.00
5. APPROXIMATION 1.60 0.49 1.93 0.25 3.27 0.002

Above table shows that, condition of episiotomy wound healing mean score of experimental group are 1.10, 1.16,
0.90,0.36, 1.6 and standard deviation are 0.30, 0.37, 0.40, 0.49, 0.49 .respectively whereas mean score of control
group are 1.60, 1.96, 1.33, 0.96, 1.93 and standard deviation are 0.49, 0.32, 0.47, 0.41 and 0.25 respectivel y. Hence
there is significant difference between Mean and SD of episiotomy wound healing parameters in experimental and
control group. p value less than 0.005, it shows that pineapple (stem) extract application is effective in episiotomy
wound healing.

Table 6: mean scores and s.d. of wound healing in experimental and control groups
n = 30 + n = 30

Group Frequency Mean S.D. t value P value

Experimental 30 5.13 0.97
11.79 0.000
Control 30 7.83 0.79
The average wound healing score of experimental before application of pineapple extract for five days and
group was 5.13 with standard deviation of 0.97. The findings were recorded.The episiotomy wound healing
average wound healing score of control group was 7.83 parameters mean scores in experimental group is
1.10,
with standard deviation of 0.79. The test statistics value
1.16, 0.90,0.36, 1.6 and standard deviation is 0.30, 0.37,
of the unpaired t test was 11.79 with p value 0.000. This
0.40, 0.49, 0.49, respectively whereas wound healing
shows that there was significant difference in the average
wound healing score at 5% level of significance. parameters mean score in control group is 1.60,
1.96,
1.33, 0.96, 1.93 and standard deviation is 0.49, 0.32,
Conclusion 0.47,
0.41 and 0.25 respectively. This shows there is significant
The study was conducted to assess the effect of
difference between Mean and SD in experimental and
pine apple extract on episiotomy wound healing. For
control group .p value is less than 0.005,
this study the quasi experimental pre post test design
was used, 60 samples were selected on the basis of The average wound healing score of experimental
the sampling criteria set for the study and samples are group was 5.13 with standard deviation of 0.97. The
divided in two groups, pineapple extract application average wound healing score of control group was 7.83
group and control group.Pre observation of wound with standard deviation of 0.79. The test statistics value
was done before intervention in both the groups, post of the unpaired t test was 11.79 with p value 0.000. This
intervention observation of episiotomy wound was done shows that there is a significant difference in the average
to assess episiotomy wound healing in experimental wound healing score at 5% level of significance. Mean
group with the help of Reeda scale. score findings showed that pineapple extract application
is useful in episiotomy wound healing and there is
The intervention was done i.e. pineapple extract statistical significant difference in the intervention group
applied to the episiotomy wound twice daily and and control group. The application of pineapple extract
observation was done according to the REEDA Scale contains bromelain, which is effective in healing of
episiotomy wound Hence it is concluded that pineapple
extract application is the best and effective tropical agent
in episiotomy wound healing.
Conflict of Interest: Nil 4. Dr. Vinita Salvi, the Pregnancy Handbook for
Indian Moms: A Doctor’s Answers to All Your
Source of Funding: Self
Questions, Sep 2013; 23-25.
Ethical Clearance: Institutional Ethical Committee, 5. Nutan Lakhanpal, Pregnancy: The Complete
meeting was held in Bharti Vidyapeeth (Deemed to Be Childbirth Book, – 1st edition, March 2004; 14-16
University) College of Nursing, Sangli and research
proposal was approved. Permissions were obtained from 6. Annamma Jacob. Comprehensive Text book
Private hospitals of Sangli and Miraj to conduct pilot of Midwifery and Gynecological Nursing, 3rd
study and the main study after I.E.C. Permission from Edition, 2012; 440-42.
Medical Superintendent was obtained for autoclaved 7. D.C. Dutta, text book of obstetrics, 7th edition,
materials required for episiotomy wound dressing. 2011; 150-51.
Purpose of the study was explained to postnatal mother
8. Neelamkumari, Shivani Sharma, Dr Priti Gupta,
and informed written consent was obtained from the
midwifery and Gynecological nursing, 1st edition,
subject prior to conduct study. Data collected from
2011; 352-353.
participants was kept confidential.
9. Annamma Jacob. Comprehensive Text book
REFERANCES of Midwifery and Gynecological Nursing, 3rd
Edition, 2012; 215-18.
1. D.C. Dutta, text book of obstetrics, 7th edition,
2011: 64-65. 10. SP Devi, The hand book of Horticulture.
Directorate. Pineapple.
2. Annamma Jacob, Comprehensive text book of
Pineapple: Health Benefits, Risks & Nutrition
midwifery and Gynecological nursing, 3rd edition
Facts, 1st Edition, 2009; 5-6.
2018; 255-58.
11. Fran Beauman: The Pineapple: The King of Fruits:
3. Neelamkumari, Shivani Sharma, Dr Priti
Gupta, Bromelain: Uses, Side Effects, Interactions,
midwifery and Gynecological nursing, 1st edition, Dosage, and Warning. 1st Edition; Nov 2006; 17-
2011; 119-23. 19.
DOI Number: 10.5958/0976-5506.2019.01600.0

Assessment of Clinical Profile of Patients with Blunt

Abdominal Trauma Admitting to Emergency Department

Ashok Y Kshirsagar1, Pratik D. Ajagekar2, Ajay Aggarwal3, Shekhargouda Deshetti3

1
Professor, 2Assistant Professor, 3Junior Resident, Department of Surgery, Krishna Institute of
Medical
Sciences deemed to be University, Karad, Satara, Maharashtra

ABSTRACT
Background: Abdominal trauma caused by blunt force is a common presentation in the emergency room
seen in adults and children. The management of the patient with blunt abdominal trauma remains in
continuous flux. Hence; we planned the present study to assess the clinical profile of patients with blunt
abdominal trauma admitting to emergency department.
Materials & Method:A total of 200 patients were included in the present study. Complete clinical details
of all the patients were obtained. Chest X-ray was carried out in all the patients. Computed tomography
(CT) was also done in all the patients. This was followed by grading of the liver, spleen and gut according
to their CT findings.Higher grade indicated higher severity of the trauma.
Results: In the present study, a total of 200 patients were analysed. Abdominal distension was found to
be present in 152 patients (76 percent). Chest X ray findings were analysed in all the patients and it was
observed that Chest X-ray revealed abdomen with air under diaphragm in 9 percent of the patients. On
doing CT liver, it was observed that grade zero was present in 98 patients while grade three and four were
present in 30 patients each.
Conclusion: In patients with blunt abdominal trauma, it is comparatively unreliable to diagnose the
patient
clinically. Rather radiograph and CT evaluation of the patients should be done for finalizing the treatment
planning.

Keywords: Abdominal,Blunt,
Trauma

Introduction Assistant Professor, Department of

Surgery, Krishna Institute of Medical
Abdominal trauma caused by blunt force is a Sciences
common presentation in the emergency room seen in Deemed to be University, Karad, Satara, Maharashtra
adults and children. The chief cause of blunt abdominal
trauma is motor vehicle accidents. Other rare causes
include falls from heights, bicycle injuries, injuries
sustained during sporting activities, and industrial
accidents. Abdominal injuries require surgery in
about
25% of cases. 85% of abdominal traumas are of blunt
character.1- 3 The spleen and liver are the most
commonly injured organs as a result of blunt
trauma. Clinical examination alone is inadequate
because patients may

Corresponding Author:
Pratik D. Ajagekar
have altered mental status and distracting injuries.The
management of the patient with blunt abdominal trauma
remains in continuous flux. The emergency physician
cannot place undue reliance on physical examination,
and plain radiography of the abdomen rarely adds to
patient care. Laboratory tests particularly elevated liver
function tests or a large base deficit, may increase our
suspicion for intra-abdominal trauma.4- 6 Hence; under
the light of above obtained data, we planned the present
study to assess the clinical profile of patientswith blunt
abdominal trauma admitting to emergency department.

Materials & Method

The present study was conducted in the Department

of Surgery, Krishna Institute of Medical Sciences
deemed to be University, Karad, Satara, Maharashtra
and it included analysis of clinical profile of the patients
with blunt abdominal trauma admitting to emergency
390 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

department. A total of 200 patients were included in the Table 3: Distribution of subjects according to
present study. Ethical approval was obtained from the abdomen distension
ethical committee of the institution.Complete clinical
Abdomen distension Frequency
details of all the patients were obtained. Chest X-ray
was carried out in all the patients. Computed Absent 48
tomography (CT) was also done in all the patients. This Present 152
was followed by grading of the liver, spleen and gut Total 200
according to their CT findings.4, 5Higher grade indicated
Table 4: Distribution of subjects according to chest
higher severity of the trauma. All the results were
X- ray Abdomen with air under diaphragm
recorded in Microsoft excel sheet and were analysed by
SPSS software. Parameter Frequency
Absent 182
Results Present 18
Total 200
In the present study, a total of 200 patients were
analysed. Mean age of the patients of the present study
was 38.4 years. Majority of the patients belonged to the
age group of 21 to 40 years. 91 percent of the patients in
the present study were males while the remaining were
females. Abdominal distension was found to be present
in 152 patients (76 percent). Chest X ray findings were
analysed in all the patients and it was observed that
Chest X-ray revealed abdomen with air under diaphragm
in 9 percent of the patients.
Graph 1: Distribution of subjects according to CT
In the present study, on doing CT liver, it was Liver grading
observed that grade zero was present in 98 patients while
grade three and four were present in 30 patients each.In
the present study, on doing CT spleen, it was observed
that grade zero was present in 150 patients while grade
three was present in 30 patients.In the present study, on
doing CT gut, it was observed that grade zero was
present in 195 patients while grade one was present in 5
patients.

Table 1: Age-wise distribution of subjects Graph 2: Distribution of subjects according to CT

Age group (years) Frequency Spleen grading
<20 18
21-40 138
41- 60 36
>60 8
Total 200

Table 2: Gender-wise of the distribution of subjects

Gender Frequency
Male 182 Graph 3: Distribution of subjects according to CT
Female 18 Bladder
Total 200
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 391
Discussion hematocrit, white blood cells count, INR, number and
time blood transfusion, hemodynamic stability, type of
In the present study, a total of 200 patients were
treatment provided, hospitalization period, morbidity
analysed. Mean age of the patients of the present study
and mortality. Assessment of splenic injuries was
was 38.4 years. Majority of the patients belonged to the evaluated according to Abbreviated Injury Scale (AIS).
age group of 21 to 40 years. 91 percent of the patients The overall mortality ratio was of 19.1% (13 patients).
in the present study were males while the remaining The average ISS value in patients who died was of
were females. Davis JJ et al, in their study, highlighted 41.92 ± 12.48, whereas in patients who survided was
the diagnosis and management of blunt abdominal of 23.33 ± 10.15. The difference was considered to be
trauma patients. The records of 437 patients with statistically significant (p <0.001). The relashionship
blunt abdominal trauma were reviewed and computer- between the ISS and AIS values in patients who died
analyzed. There was an 80% increase in the incidence was considered directly proportional but not statistically
of blunt abdominal trauma when compared with the significant (Pearson test AIS/ISS = 0.132, p = n.s.). The
preceding 15-year experience. Forty-three per cent of all initial management was a conservative treatment in 27
the patients presented with no specific complaint or sign patients (39.7%) of them 4 patients (15%) failed, in the
of injury. Blunt abdominal injury was usually diagnosed other 41 cases urgent splenectomies were performed.
preoperatively using conventional methods including Splenic injury, as reported in our statistic as well as
history, physical examination, and routine laboratory in literature, was the most common injury in closed
tests and x-rays. Abdominal paracentesis via a Potter abdominal trauma.8
needle had an 86% accuracy. The incidence and
management of specific organ injuries with associated Trauma is one of the most common causes of
morbidity and mortality have been discussed. Mortality morbidity and mortality. After the evaluation and
and morbidity continued to be significant in blunt resuscitation of trauma patients, a detailed physical
abdominal trauma. Isolated abdominal injuries rarely examination should be made. As a single physical
(5%) resulted in death, even though abdominal examination is not sensitive, serial physical
injuries accounted for examinations are required. For subjects with abdominal
41% of all deaths. Associated injuries, especially head injury who were admitted to emergency treatment,
injury, greatly increased the risk. The insidious nature ultrasonography (US) and computed tomography (CT)
of blunt abdominal injury was borne out by the fact that are the most commonly used radiological tests.
more than one-third of the “asymptomatic” patients had Sensitivity of US is between 56-97% for determining
an abdominal organ injured.7 hemoperitoneum in the intra-abdominal organ injury.
CT is the gold standard in the diagnosis of abdominal
In the present study, abdominal distension was injuries. CT especially provides utility in planning
found to be present in 152 patients (76 percent). Chest conservative treatment and follow-up by classifying
X ray findings were analysed in all the patients and it solid organ injuries in blunt abdominal injuries.9- 11
was observed that Chest X-ray revealed abdomen with
air under diaphragm in 9 percent of the patients.In the Conclusion
present study, on doing CT liver, it was observed that
grade zero was present in 98 patients while grade three Under the presence of above obtained results, the
and four were present in 30 patients each.In the present authors conclude that in patients with blunt abdominal
study, on doing CT spleen, it was observed that grade trauma, it is comparatively unreliable to diagnose the
zero was present in 150 patients while grade three was patient clinically. Rather radiograph and CT evaluation
present in 30 patients.In the present study, on doing of the patients should be done for finalizing the
CT gut, it was observed that grade zero was treatment planning.
present in
195 patients while grade one was present in 5 patients. Ethical Clearance: Taken from. Institutional Ethical.
Fransvea P et al assessed splenic trauma treatment, committee
with particular attention to conservative treatment,
Source of Funding: Self
its limits, its efficiency, and its safety in multi-trauma
patient or in a severe trauma patient. The variables taken Conflict of Interest: Nil.
into account were spleen injury and general injuries,
age, sex, cause and dynamic of trauma, hemoglobin,
392 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

REFERENCES 7. Davis JJ, Cohn I Jr, Nance FC. Diagnosis and

1. van der Vlies CH, Olthof DC, Gaakeer M. management of blunt abdominal trauma. Ann
Changing patterns in diagnostic strategies and Surg. 1976;183(6):672–678.
the treatment of blunt injury to solid abdominal 8. Fransvea P, Costa G, Massa G, Frezza B,
organs. Int J Emerg Med 2011;4:47. Mercantini P, BaIducci G. Non-operative
2. Lowe RJ, Boyd DR, Frank CM, Baker RJ. The management of blunt splenic injury: is it really
negative laparotomy for abdominal trauma. J so extensively feasible? a critical appraisal
Trauma 1997; 2:853-61 of a single-center experience. Pan Afr Med J.
2019;32:52. Published 2019 Jan 30. doi:10.11604/
3. Fernandes T Marconi, EscociaDorigatti A, pamj.2019.32.52.15022
Monteiro BT. Nonoperative management of
splenic injury grade IV is safe using rigid 9. Karamercan A, Yılmaz TU, Karamercan MA,
protocol. Rev Col Bras Cir 2013;40: 323-8 Aytaç B. Blunt abdominal trauma: evaluation
of diagnostic options and surgical outcomes.
4. Taviloglu K, Yanar H. Current trends in the UlusTravmaAcilCerrahiDerg. 2008;14:205–10.
management of blunt solid organ injuries. Eur J
Trauma EmergSurg 2009;35:90-4. 10. Davis JJ, Cohn I, Nance FC. Diagnosis and
management of blunt abdominal trauma. Ann
5. Wang S-Y, Liao C-H, Fu C-Y, Kang S-C. An Surg. 1976;183:672–8
outcome prediction model for exsanguinating
patients with blunt abdominal trauma after 11. Leone RJ, Hammond JS. Nonoperative
damage control laparotomy: a retrospective study. management of pediatric blunt hepatic trauma.
BMC Surg 2014;14:24. Am Surg. 2001;67:138–42

6. Morton J, Hinshaw R. Blunt trauma to the

abdomen. Ann Surg 1957;145:699-711
DOI Number: 10.5958/0976-5506.2019.01601.2

Comparative Study of Semen Analysis in Fertile and

Infertile Males

Joy A K Ghoshal1, Anil Kumar Reddy2

1
Professor and Head, 2Tutor, Department of Anatomy, All India Institute of Medical
Sciences, Mangalagiri, Andhra Pradesh

ABSTRACT
Background: Prediction of male fertility potential on the basis of semen quality remains desirable but
an elusive goal. There are no objective morphological criteria for defining normal spermatozoa in human
semen. The morphometric diversity in the semen sample may be a useful measure of morphologic integrity.
Aim: The present study was undertaken to analyze the various parameters of semen analysis in fertile and
nonfertile males and to analyze the role of collective parameters in infertility.
Materials & Method: The study was carried out in the department of anatomy. A total of 200 Semen
samples were collected from the patients visiting private pathology laboratories and infertility centers
located in and around Vijayawada city.
Results: In the macroscopic examination no significant difference was noted in infertile couples
(experimental) for the parameters liquefaction, appearance, volume, viscosity, and pH when compared with
a fertile group (control). In the microscopic examination, no significant difference was detected in
agglutination and other cells in both groups.
Conclusion: The presence of subnormal values in the semen analysis report should not be regarded
as a
cause of infertility.

Keywords: Semen analysis, Spermatozoa, Motility, Microscopic and

Macroscopic
Introduction Approximately 72.4 million couples worldwide
experience fertility problems, there are no reliable
Infertility is the problem faced by mankind since
figures for the global prevalence of infertility.2 WHO
its evolution on the earth. According to World Health
estimated that 8-12% of couples worldwide affect
Organization (WHO) and International Committee
infertility.1
for Monitoring Assisted Reproductive Technology,
In India, the overall prevalence of primary infertility
infertility is a disease of reproductive system defined as
ranges from 3.9% to 16.8%. It varies widely among
failure of couple to conceive after 12 months of regular
Indian states from 3.7% in Uttar Pradesh, Himachal
intercourse without the use of contraception in
Pradesh, and Maharashtra, to 5% in Andhra Pradesh,
women
and 15% in Kashmir. It was also reported that 40% of
<35 years; and after 6 months of regular intercourse
infertility cases were related to men, approximately 23%
without the use of contraception in women ≥35 years.1
of the malefactor is the cause among the couples seeking
treatment for infertility.2, 3

Infertility and problems of impaired fecundity have

Corresponding Author: been a concern through ages and is also a significant
Anil Kumar Reddy clinical problem today, which affects 8–12% of couples
Tutor, Department of Anatomy, worldwide. Of all infertility cases, approximately 40–
All India Institute of Medical Sciences, 50% is due to “male factor” infertility and as many as
Mangalagiri, Andhra Pradesh 2% of all men will exhibit suboptimal sperm
Email: [email protected] parameters. It may be one or a combination of low
sperm concentration,
394 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 394

poor sperm motility, or abnormal morphology.4 The explained the procedure of collection of the sample
rates of infertility in less industrialized nations are by masturbation within the laboratory premises in
markedly higher and infectious diseases are responsible the collection room. Semen was collected in sterile
for a greater proportion of infertility.5, 6 transparent circular glass jars of 7cms height with a
diameter of 4 cm at the bottom and 6 cm at the top.
Semen analysis is the most important diagnostic
tool for evaluation of the role of males in infertility. Analysis of the Sample: After liquefaction of the
Compared to many other tests used in the assessment sample, the following parameters were measured;
of the infertile couple, semen analysis has been
1. Macroscopic examination– Liquefaction,
standardized throughout the world. The semen analysis
appearance, volume, viscosity, semen pH
includes a sequence of steps; collection semen sample,
evaluation of the physical properties of the semen such 2. Microscopic examination:
as liquefaction, viscosity, semen volume and seminal a. Morphology of spermatocytes by examining
pH, determination sperm motility, vitality, counting of stained slides
spermatozoa, assessment of sperm morphology, b. Motility
counting of other sperm cells, Biochemical assays
including the measurement of fructose, zinc and The motility of each spermatozoon was assessed by
epididymal glucosidase are outlined. 7, 8 grading them into four groups as follows:
a = rapid- progressive motility
There are scanty reports about the study of all the
(>
macroscopic and light microscopic parameters in a 25u/second)
semen sample and their correlation in both fertile and
b = slow- progressive motility
infertile groups. The study aimed to analyze the role
(5-
of various parameters of macroscopic and microscopic
25u/second)
examination of semen in infertility and also aims to
analyze the role of collective parameters in infertility. c = non- progressive motility
(<
5u/second)
Materials & Method
d = immobility
The present study was carried out on patients c. Estimation of cells other than spermatozoa
visiting private pathology laboratories and infertility The cells were detected on the basis that
centers located in metropolitan cities. A total of 200 they lacked the typical characteristics of
semen samples were studied, in which 100 experimental spermatozoa, the typical head, midpiece, tail,
and 100 control groups. The collected data was analysed their presence or absence was recorded. The
in the Department of Anatomy, All India Institute of number of round cells detected during the
Medical Sciences, Mangalagiri. examination of various fields for counting 200
spermatozoa was noted.
The infertile patients were sent to the laboratories
for investigations from various clinicians in and around The total number of round cells was calculated
the city. Both wife and husband were investigated for with the help of the following formula:
the cause of infertility. After the complete investigation, Round cells in millions/mt= Round cells
if the female partner was detected as fertile and the counted/200 sperms x Sperm concentration in
male partner detected infertile were included in the millions/ml100
experimental group. If the female partner was detected d. Vitality: The test is based on the principle that
as infertile then her husband was included in the control dead cells with damaged plasma membrane take
group. The history of the subjects and consent form from up certain stains. The number of live
both partners were taken. spermatozoa is measured during the motility
counting test.
Sample Collection: The subjects were advised
to e. Total count of spermatocytes: Evaluation of
observe abstinence from intercourse for 3-4days and actual sperm concentration was done after
dilution, which was decided on the basis of the
395 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 395
two averages for the sample recorded during
the preliminary estimation of concentration.
Table 1: showing dilutions and conversions factor for the Neubauer Haemocytometer

Initial Microscopic examination The conversion factor in Haemocytometer

Sperms/400x field Dilution (Semen+Diluent) 25 10 5
<15 1:5 (1+4) 20 8 4
15-40 1:10 (1+9) 10 4 2
40-200 1:20 (1+19) 5 2 1
>200 1:50 (1+49) 2 0.8 0.4
Preparation of smear and staining: Smears were volume ranging from 2ml to 4.5ml. The mean volume
prepared by placing the drop of semen on pre-cleaned in the experimental group was 3.4 ± 0.38ml and in the
slides by feathering technique and air dried. Smeared control group 3.46 ± 0.46ml. No difference was seen
slides were stained by modified Papanicolaou staining. in the median value (3.4 ml) while the mode value for
The stained slides were examined on the same day with the experimental group was less by 0.06ml than that in
the use of a binocular microscope. the control group, it was statistically insignificant. The
viscosity was within normal limits with the formation
Statistical Analysis: The collected data was entered
of thread less than the 2cm length for all the samples in
in excel sheets, Mean, standard deviation, standard
the experimental and control group. All samples in the
error of the difference between two means (Control and
present study showed pH within the range of 7.0 to 8.0.
Experimental) and ‘z’ value were calculated using SPSS
software. P value is <0.05 considered as significant. 2. Microscopic examination:
a. Morphology of spermatocytes: The
Observations & Results morphology of spermatozoa was observed in
stained slides and categorized into head, neck,
The macroscopic examination of semen analysis mid-piece and tail defects. It was observed that
was done in both control and experimental groups to in the experimental group the percentage of
know the Liquefaction time, Appearance, Volume, morphologically normal sperms varied from
Viscosity, pH of the semen. 2 to 52%, abnormal sperms varied from 48%
All the samples in both experimental and control to 98%. The percentage of morphologically
group liquefied within thirty minutes. Semen samples in normal sperms varied in the control group from
both experimental and control groups of the present 80 to 91%, abnormal sperms varied from 9
to
study were having a homogenous grey opalescent
appearance. All the 200 samples in the present study 20%. The mean differences in the percentage of
showed the abnormal sperms were statistically significant.

Table 2: Shows the Mean differences in abnormal sperms in the experimental and control groups

S. % Abnormal sperms
Study groups ‘P’ value
No. Mode Median Mean ± SD
1. Experimental 54 54 45.52 ± 6.24 0.001
2. Control 10 13 13.15 ± 3.08
*P≤0.05 considered as significant
Even though a various number of defects were categorized for each part of spermatozoa, in the present
study four varieties of head defects are seen; those are Tapering, Pyriform, Amorphous, Double Heads.
One variety of neck defects, two varieties of a mid-piece defect and two varieties of tail defects were found
while examining the stained slides under the binocular microscope.
Table 3: Shows various morphological defects of spermatozoa

S. No. Type of defects Group Mode Median Mean ± SD ‘P’ value

Exp. 40 20 20.40+-6.73
1. Head defects <0.001
Control 3 18 1.25+-0.96
Exp. 2 2 21.14 ± 1.86
2. Neck defects <0.001
Control 2 1 1.23 ± 0.93
Exp. 0 0 0.76 ± 2.01
3. Mid-piece defects <0.001
Control 0 0 0.44 ± 0.57
Exp. 0 0 1.61 ± 2.04
4. Tail defects >0.05
Control 2 2 1.78 ± 0.63
Exp. 6 6 6.64 ± 3.46
5. Cytoplasmic droplets <0.001
Control 5 5 4.77 ± 2.07
*P≤0.05 considered as significant
b. Motility: Motility of the spermatozoa was assessed by grading as described in the methodology. The
difference between the experimental and control groups was significant in a-grade, b-grade, and c-grade
motility and not significant in d-grade motility.

Table 4: Showing mode, median and mean values of the different grades of motility of the
experimental and control group
S. No. Grades of motility Group Mode Median Mean ± SD ‘P’ value
Expt. 20 20 20 ± 0.36
1. a grade <0.001
Ctrl. 30 30 28.55 ± 7.40
Expt. 30 30 32 ± 9.74
2. b grade <0.05
Ctrl. 30 30 29.10 ± 8.05
Expt. 30 30 27 ± 10.1
3. c grade <0.001
Ctrl. 30 20 22.45 ± 9.49
Expt. 10 20 21 ± 13.52
4. d grade >0.05
Ctrl. 30 20 19.90 ± 9.67
*P≤0.05 considered as significant
c. Estimation of cells other than spermatozoa: normal limits. However, 65 cases out of the
Round cells were observed in both total 100 in an experimental group, showed
experimental and control group samples. the vitality percentage within normal limits
Round cells less than or equal to one million (>74%). In 35 samples of the experimental
per ml were found in 83 cases of group, the vitality percentage was in the range
experimental and 92 cases of the control of 60 to 73%. The mean differences between
group. More than one but less than the experimental and control groups were
2 million per ml was seen in 14 cases of the statistically significant.
experimental group and 8 cases of the control e. Total count of spermatocytes: The mean
group. In 3 cases of the experimental group, the values were 192.48 ± 71.61 million and 269.03
number of round cells was more than 5 million ± 59.49 million for the experimental and control
per ml. groups respectively. On comparing the mean
d. Vitality: The percentage of vital spermatozoa differences of total spermatozoa count in control
in the control group was more than 74% in and experimental group was found significant
control group cases, which was within the
Table 5: Showing the mean differences between spermatozoa vitality and total count in experimental
and control group samples

S. No. Variables Study groups Mode Median Mean ± SD ml ‘P’ value

Experimental 80 80 82 ± 6.78
1. Vitality 0.05
Control 85 85 84.45 ± -6.31
Total sperm Experimental 129.2 198 193.48 ± 71.61
2. 0.001
count Control 320 272.8 269.03 ± 59.49
*P≤0.05 considered as significant
Discussion the current study is in conformity with Aitken, R. J. et
al (1982)6, Rogers et al (1983)14. The results reported
Infertility severely affects the couple’s psychological
by Narayan et al (1981)15 are higher the percentage of
harmony, sexual life, and social function. The individual
abnormal sperms as compared with current findings.
couple desiring a child but unable to conceive one, feel
demanded, deprived and bitter. The inability to procreate Analysis of retrospective data indicates that sperm
is thus always perceived as a denial of basic rights, counts may have declined in some parts of the world,
injustice, and a disappointment sometimes bordering on but there seem to be geographical variations in the
grief. semen quality.16 The reason for geographic variations
in semen characteristics is not clear, but it may be due
An internationally accepted method of classification to environmental, nutritional, socioeconomic, or other
of grades of motility was used in the present work. unknown causes. The decline in the semen quality
The percentage of grade wise motile sperms observed coincides with an increased incidence of abnormalities
in the present study was in agreement with reports of of the male genital tract including testicular cancer and
Aitken R J (1982)6, Bonde J P E (1998)9, Menkveld R cryptorchidism in various countries.
(2011)10. While comparing the motility in the
present
15, 16

work it was observed that there is no significant

difference in the d-grade motility in the experimental Conclusion
group when compared with the respective grade in the
With the findings of the present work, we propose
control group. This indicates that the presence of rapidly
that the fertilizing capacity of an individual should
progressive motile sperms in a good number is essential
not be assumed as within normal limits by the mere
for fertilization.11 Reduced calcium from the prostate,
presence of all the parameters of semen analysis within
increased secretion of MIF from the epididymis and
normal limits. Similarly, the presence of some of the
decreased MSF from Sertoli cells are the major cause
affecting the sperm motility.12 Cholesterol containing parameters better than the average also fails to conclude
floating vesicles in the semen may inhibit the calcium the fertilizing capacity of an individual. On the other
permeability and thus indirectly the motility.11, 12 hand, the mere presence of subnormal values in the
semen analysis report should not be regarded as a cause
A recent study was done by Nandini Bhaduri of infertility. The degree of overlap between fertilizers
(2015)13, on sperm morphology in males exposed to and nonfertilizers for various parameters of the semen
higher temperatures showed that occupational exposure analysis is considerable.
to high temperature adversely affects sperm morphology
and motility. This leads to oligoasthenoteratozoospermia We propose that the semen can be further analyzed
(OAT). The percentage of sperms with normal in cases of unexplained infertility for its biochemical
morphology is strongly related to the likelihood constituents and fertilizing capacity. Some of the newer
of pregnancy independent of sperm concentration. parameters like sperm length: width ratio, sperm head
Bonde, J.P.E. et al (1998)9 found the mean proportion length: width ratio, acrosome index, sperm deformity
of morphologically normal sperms to be 40%. The index, multiple anomalies indexes, sperm cytochemistry
percentage of morphologically abnormal cells found etc should be studied wherever required.
in
Acknowledgment 8. Joshi P, Gopal N, Bhat V. Study of semen analysis
patterns in infertile males. Int J Pharm Bio
The authors are thankful to the fertility centers and Sci.
laboratories for their assistance in the completion of the 2011 Jan;1(1):44-9.
present work.
9. Bonde JP, Ernst E, Jensen TK, Hjollund NH,
Ethical Clearance: The study was approved by Kolstad H, Scheike T, Giwercman A, Skakkebæk
Institutional Ethical Committee. NE, Henriksen TB, Olsen J. Relation between
semen quality and fertility: a population-based
Source of Funding: Self-funded. study of 430 first-pregnancy planners. The Lancet.
1998 Oct 10;352(9135):1172-7.
Conflict of Interest: None to be declared
10. Menkveld R, Holleboom CA, Rhemrev JP.
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2. Amelar RD. Infertility in men: diagnosis and
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3. Marimuthu P, Kapilashrami MC, Misro MM, 12. Menkveld R, Stander FS, Kotze TJ, Kruger
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4. Bartoov B, Eltes F, Langsam J, Snyder M, N, GhoshTK.Abnormalities in semen analysis
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DOI Number: 10.5958/0976-5506.2019.01602.4

Recharging Ground Water using Age–Old Traditional

Mechanisms

Manbeer Kaur1, Mona Prashar2

1
Assistant Professor, B.A.M. Khalsa College, Garhshankar,District Hoshiarpur, Punjab,
India;
2
Research Scholar, University School of Business, Chandigarh University, Gharuan, Mohali District,
Punjab

ABSTRACT
“Give back unto the Earth if water is desired in the coming generations”
“Pawan Guru, Pani Pita, Mata Dharat Mahat” the Gurbani or word of the Gurus as embodied in the holy
Guru Granth Sahib has in these words immortalized the relationship of men with Nature by saying that the
“Wind is the teacher; Water is Father while the entire Earth is the mother”. When this strong bonding of
men and Nature had been recognized several centuries ago it stupefied the human senses to think that man
had ended up destroying the natural habitat unmitigatedly.
Since earliest times almost all natural resources have been reserved and utilized judiciously by civilizations.
The Chinese, Indus valley, Mesopotamian, Roman, Aztec and most other great settlements used water
conservatively. Even back then there was concern for wastage of water.
This paper is focused on looking at the systems of conserving, purifying water and utilizing it to the
optimum without wasting any part of it. The objective of the paper is to determine the functioning and use
of these techniques for present day communities.

Keywords: Earth, Ma, Nature, habitat, water, purification, conservation, techniques, civilizations,
traditional,
optimum, communities.
Problem Statement: Dimensions of Water Access villages have their waste (solid and liquid) flowing
& Excess: India’s population is over 1.3 billion. This gravitationally into their pond and they do not pay heed
population inhabits several thousands of villages in to the ominous degradation of this once healthy
each of its states and union territories besides cities and resource.
towns. Over this and the past century, water availability
to the world’s population has been declining rapidly “If the villagers do not consider their ponds to be
due to increased urbanization and urban populations. In worthy of being saved they will in their lifetimes see
India a large percentage of surface water is contained the folly of their ways” said an octogenarian in one of
and unusable. It is a disturbing fact that India as of today the villages of the Doaba region in Punjab. Taking his
uses more ground water than China and the United concerns further it can be deduced that villagers will
States put together. Needless to say the ground water gradually loose:
levels are rapidly declining all over the country but in (i) A healthy environment to live in
some regions they are doing so at an astronomical pace.
(ii) Be forced to live in a vector infested habitat
The drinking water situation in the country is
(iii) Be prone to diseases all the year round when
fast becoming a Pandora’s Box. On the one hand
neither children nor the elderly will be spared.
populations have been known to face death due to not
having sustainable access to clean drinking water and (iv) Loose the vital lungs of the village
on the other hand there is rampant waste of this precious (v) Become bereft of a vital water recharging source
commodity. The villages at one time had had wells and that could have replenished their water reservoirs.
ponds that hummed with life1. These days’ wells are
obsolete while ponds have become stench holes. (vi) Very few villagers choose to inhabit areas around
Most the villages pond.
400 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 400

(vii) Gain a little bit of extra land for settlers and loose (vi) Guards the environment against rapid climate
a major village asset like the pond. change

In most villages it can be observed that people (vii) Adds to an aesthetically appealing living
living near the pond are doing so only under duress. environment for most villagers
They have no choice, no alternative but to tolerate the
harmful, stench saturated and unhealthy environment. The pond’s ecosystem is directly connected with
the resident community the people, the decision-makers
Rejuvenation through Ponds: Once the ponds have and the implementers. The ponds also helped maintain,
optimum content of oxygen in the water special blends to a large extent, the communities’ inherent cultural and
of bacteria and enzymes can be introduced into them. economic resources. Ponds with good water quality are
These biological blends are successful at breaking down economically desirable all over the world.
organic matter. They are efficient in consuming water
borne pathogens that are causative of pollution and other The National Water Policy of India lays emphasis
bad effects of stagnation in the pond. on the significance of ponds in India. These desirables
have been underlined by several world bodies. The
Access to clean water can affect the performance of United Nation’s Sustainable Development Goals
milch animals markedly and is therefore very necessary (SDGs) have mandated that it is essential to safeguard
for healthy livestock. With availability of clean water the planet’s water resources. By 2030 AD the world’s
ponds these milk giving animals drink and eat more, and
water requirement is expected to increase by 30%. It
ultimately gain weight quicker. This directly affects their
is important to realize that ecological and ecosystem
milk yield.
security is a prerequisite for human and water security.
Downing2 in his paper titled ‘Emerging Global Role
No doubt the demand for water has accelerated over
of Small Lakes and Ponds: Little Things Mean a Lot’,
the decades because of the escalating population size
presents the concept that little water bodies do a lot for
and unsustainable consumption and production patterns
the entire ecological systems. He carefully studied small
ecosystems and proposed that ecosystems having small that have began showing their debilitating impact in
areal extent played a major role in global ecological the current century. Competition for water has severely
processes of existence. He continued that the areal impacted upon the Earth’s ecosystems and biodiversity.
extent of continental waters is dominated by ponds and Its worst effects are visible on populations in parts of
small lakes. They show a large functional intensity of the developing world where natural water resources
many ecological processes and these can be seen have been depleted and artificial water recharging
through various seasonal cycles. mechanisms have proven to be cost prohibitive.

Ponds provide sustainable solutions to most of the Significance of Ponds in the Village Habitat: There is
major issues of water management being faced from the no universally accepted definition of the term pond.
village to the global level. Thus, ponds, therefore, have Ponds can be described as a body of still surface water
been recognized as an important functional freshwater which is either natural or man-made and is quite smaller
habitat4. They play a critical role in maintaining the than a lake. These small water resources are significant
environmental biodiversity. With sensitive planning at contributors to development of local communities, and
the village level these very ponds can bring about major marginalized lower income households especially in the
benefits to the resident population in terms of: urban areas. The village ponds are essential receptors
(i) Rich, healthy Biodiversity and reservoirs for natural rainwater harvesting. They are
providential for maintaining groundwater levels,
(ii) Promoting a Healthy Environment naturally.
(iii) Pollution alleviation and promotion of a clean
According to Dubey3 who closely examined the
environment
biological diversity presented in village ponds and their
(iv) Conducive habitat for domestic animals crucial role in sustainable development established
(v) Provide flood relief during heavy rains irrefutably that there is an undeniable equation between
man and his environment.
Dubey3 details that the village ponds “conserve have combinations of three variant food webs. The first
and preserve the history, mystery and science of rural one is based on larger plants, the second one is based
realities of developing, underdeveloped and partially on decayed plants and the third is based upon algae.
developed nations.” We continues that ponds are Ponds therefore provide significant sources of biological
“intricately wedded to biological identities carrying diversity in any geographic landscapes not only for
cultural concepts and social strains associated with plants and animals but it can be observed that ponds are
religious tenets.” central to the life and wholesomeness of the entire eco-
system in rural India. Since earliest civilizations villages
Biological Diversity of Indian Village Ponds: The
have been known tooriginate around ponds. Rain water
flora and fauna of the ponds protect and preserve a wide
gets harvested naturally by the pond. It gets stored up,
variety of organisms and micro-organisms. These
rechargingthe ground water and indicating the level of
include the amphibians, aquatic invertebrates, aquatic
the water table in the village. Each pond has its own
plants and some mammals. The smallest pond is
unique biodiversity, with all participants
normally infested by a huge variety of invertebrates like
dischargingtheir specific ecosystem functions.
the dragonfly and damselfly. Species like pygmy
damselfly (Nehalennia speciosa) and island darter There is another important aspect that brings forth
(Sympetrum nigrifemur) are salient ones inhabiting and the socio-cultural significance of ponds. It is an
surviving in the pond ecosystem. These ponds are home established fact that village ponds have had and continue
to the medicinal leech (Hirudomedicinalis) and the water to have a deeply entrenched cultural andhistorical
beetle (Graphoderus bilineatus) along with a number of significance. Since centuries ponds have played a crucial
other creatures that are determined by the lay of the role inmaintaining and encouraging the vital link
land, the temperatures and the population pressures. betweenpeople and wildlife. There are numerous
Being a complete ecosystem the pond is home to socio-psychological links that have been established
several commonly sighted birds like the egrets, the between ponds and their resident settlements. Several
pond herons, the red wattled lapwings, the cormorants, rituals are associated with ponds. There are several
the kingfishers, the ducks, the geese, the swans and the periodic, lesser or major monthly and annual fairs that are
cranes alongwith a variety of others. In some areas these held on the banks of ponds. These are a significant salient
ponds are breeding grounds for a large number of reality even in the present times. The Biodiversity Value
migratory birds. of ponds is reinforced on the basis of three fundamental
truths:
The plants growing in the pond provide food,
oxygen and shelter to animals. Ponds in the open are (i) Their status as a critical habitat for
healthier than ponds in the shade because they have uncommon
access to sunlight to make their food. The smallest and rare species
plants in a pond are the microscopic phytoplankton (ii) Their role as stepping stone habitats for upward or
which provide most of the food in a pond. The downward mobility of flora and fauna
phytoplankton and larger algae form the first part of the
pond’s food chains. Pond vegetation grows in ‘zones’. (iii) Their value as thriving biodiversity hot spots
Plants like the great willow herb and meadow sweet
Threats to Ponds Biodiversity: Severe pollution of
grow in the bank side zone. They like damp places but
ponds is being done by the dumping of wastes, chemical
are not true water plants. The yellow iris and mud-sedge
pollutants like the powdery chemical fertilisers having
grow nearest the pond edge or the marsh zone. The
nitrates that are washed off by rain into the nearby
ponds are potent shelters for several categories of
ponds. This rich supply of nitrogen causes water plants,
microbes. They comprise bacteria, protozoa, algae and
like algae to grow rapidly. These plants use up much
rotifers.
oxygen during the night and during their decaying
Dynamism of Pond Life and Biodiversity Value: processes that virtually none is left for the remaining
Ponds have a distinctive life in which are featured pond-life forms. This unmitigated growth also prevents
different kinds of organisms which live in a number sunlight from reaching the organisms below. The past
of networks that are interdependent and inter reactive. century has seen about forty percent of the old village
They share the available food to live and reproduce. ponds being choked and filled up for residential or
Different types of foods are found in ponds because pasture and even cropping purposes. Currently there
each animal eats different things. A pond, thus, may
are several villages in Punjab that are totally devoid of
any water body.
Figure 1: Interactive Relationships of Village Ponds
The above figure gives the almost symbiotic 3. Village Guru, Block Jagraon, District Ludhiana
relationship network that develops between ponds
4. Village Dewatwal, Block Ludhiana, District
and their human, flora and fauna partners. These may
be positive or negative depending upon the needs Ludhiana
and exploitative overtures of the users of the pond The Waste Stabilization Ponds (WSP) do not
environment. require any electrical energy. They are extremely
Government and Community Approach to Pond efficient. They efficiently remove excreted pathogens.
Restoration: Most village ponds require a pragmatic The success and progress attained by WSPs is largely
approach for their eco-restoration. The channelization because the systematic stage-wise implementation of
of free flowing rain water from the village catchments various steps of the process are measureable and
is essential for sustainable eco-restoration of ponds. standardized on the basis of internationally
Another significant task is the stocking of various niches experimented and implemented procedures.
of the pond with native vegetation and animals.
(i) The first stage of waste water treatment is the
This essential task of systematic eco-restoration removal of large floating particles and heavy
and sustained management of ponds requires several mineral particles like sand and grit. This is done
collective steps to be taken in tandem by individuals, by simple screening and grit removal a good
groups and organisations acting in unison. duration before the raw waste water enters the
other parts of the WSP.
The Chief Minister of Punjab, had vide his D.O.
letter dated 22nd March, 2012, detailed the problems (ii) Secondly, the measurement of the incoming waste
related to the disposal of waste water and need of water is important. This measurement is essential
rehabilitation of village ponds in Punjab. He appraised for determining diurnal flow variations and for
the Minister for Rural Development, Drinking Water constantly evaluating the performance of the
and Sanitation that some pilot projects using the treatment system.
technology of UNICEF and Government of India had (iii) The system comprises three treatment units:
been in Ludhiana and Muktsar districts and should be
replicated all over the State. 1. Anaerobic pond

Subsequently, a team was constituted of various 2. Facultativepond

experts to study the situation of ponds and how they 3. Maturation pond
could be resurrected. The team looked into the status and
survival of ponds in the following villages: The anaerobic and facultative ponds are designed
for BOD removal and the maturation ponds are designed
1. Village Mohlan, Mandal Malout, District Muktsar
for faecal bacteria removal.
2. Village Birk, Block Sidhwan Bet, District
Ludhiana
a. Anaerobic Ponds: These are 2 to 5 metres deep (iii) A protocol for ground water quality monitoring
tanks that receive high organic loading, more should be developed to regularly monitor ground
than 100 gms BOD/cum. Day. It is equivalent water quality near such WSPs.
to
(iv) Boulders can be used for inner embankment of
3000Kg./ha day, containing no dissolved oxygen
ponds, up to the waste water level to check soil
and no algae. The primary function of these units
erosion.
is BOD removal.
b. Facultative Ponds: These units are designed Convergence with various government departments
for BOD removal on the basis of low surface is envisaged, especially the Departments of Rural
BOD loading. It is usually in the range of 100- Development, Health as well as Forests and
400kg/ha day to permit development of healthy Environment besides Water and Sanitation. All these
algalgrowth, because the Oxygen for BOD departments need to pool their efforts in giving a new
removal by pond bacteria is mostly produced by lease of life to the stagnating pond wealth of Punjab.
algal photosynthesis. Liquid depthis usually in the Needless to say this would not be practicable without
range of 1 – 1.8 mts, 1.5 mts. the total participation of the community.

c. Maturation Ponds: The main maturation pond Conflict of Interest: Nil

reduces the number of excreted pathogens, mainly
faecal bacteria and viruses present in effluents Ethical Clearance: Taken from The Rural
from the facultative ponds. These ponds are Environmental Enterprises Development Society (The
typically aerobic. The depth of these maturation REEDS) committee
ponds isabout one metre. Shallow ponds are more Source of Funding: Self
efficient due to greater light penetration.

The principal mechanism for faecal bacteria removal REFERENCE

in these and facultativeponds are: 1. Cereghino, R., Boix, D., Cauchie, H-M., Martens,
(i) Temperature K., and Oertli, B. The Ecological Role of Ponds
in a Changing World. Hydrobiologia,. 2014; 723:
(ii) HighpH values
1-6.
(iii) High light intensity
2. Downing, J. A. Global Role of Small Lakes and
Ponds: Little Things Mean a Lot. Limnetica.
Conclusions and Policy Implications 2010; 29(1): 9-23.
It has been derived from the foregoing narrative 3. Dubey, T. P. The Biodiversity of the Ponds.
that rejuvenation and resurrection of village ponds is Water and Biodiversity, Uttar Pradesh State
essential for the sustained promotion of human Biodiversity Board 2015; 30-36.
habitation conducive environments. Water is a rare
4. Krishnamurthy, Radha. Water in Ancient India
source of life with increased ability to make informed
Indian Journal of History of Science. 1996; 31 (4).
choices. The following are some suggestions that may
have policy implications at the state and national level. 5. Ray, M. K., and Majumdar, S.. Evaluating
Economic Sustainability of Urban and Peri-urban
(i) Waste Stabilisation Pond 5 technology is the
Waterbodies: A Case Study from Kolkata Ponds.
simplest, suitable technology to treat waste water
Editors: Sengupta, N., and Badyopadhyay, J.
in rural areas.
Biodiversity and Quality of Life, Macmillan, New
(ii) Places having high water table may be in danger Delhi,. 2005; (): 135-146.
of ground water pollution.
DOI Number: 10.5958/0976-5506.2019.01603.6

MRI Image Training and Finding Acute Spine Injury with the
Help of Hemorrhagic and Non Hemorrhagic Rope Wounds
Method

Sk Hasane Ahammad1, V Rajesh2, N Hanumatsai3, A Venumadhav3, NSS Sasank3, KK Bhargav Gupta3,

Syed Inithiyaz4
1
Research Scholar, 2Professor, 3Students, 4Associate Professor, Department of Electronics and
Engineering, KoneruLakshmaiah Education Foundation, Guntur, India

ABSTRACT
Magnetic resonance imaging (MRI) has been assuming an undeniably vital job in the spinal injury patients
because of high affectability for discovery of intense delicate tissue and line wounds. An ever increasing
number of patients are experiencing M.R.I on behalf of spinal injury in the crisis situations, accordingly
requiring the deciphering doctors to subsist comfortable through M/R/I discoveries in spinal injury. In this
pictographical survey, we determination initially portray the ordinary life systems of different ligamentous
arrangement. Signs of M-R-I in spinal injury just as the job of MRI in makes a diagnosis spinal rope as
well as delicate hankie wounds will at that point be examined. Delineated belongings are mostly of cervical
backbone injury, however thoracolumbar spine wounds are likewise included where proper in our audit.

Keywords: Spinal trauma, MRI, Spinal cord, Hemorrhage, Ligamentous

injury
Introduction injury patients. Prominently, M-R-I is the methodology
of decision in favor of assessment of ligament us
Imaging assumes a basic job in analysis of intense
alsoadditional delicate hankieorganizations, circle,
spinal injury and aides in starting brief and exact action
spinal rope as well as mysterious bony wounds. In this
in these patients. Regular radio-graphs furthermore,
pictorial audit, we will initially depict the typical life
Computed/Tomography(C/T) is the underlying imaging
systems of different ligamentous structures including the
modalities utilized in the determination of the majority
craniocervicalintersection1. At that point, signs of MRI
instances of spinal wounds. Whereas strength of the
in spinal injury just as the job of M/R-I in make a
back might subsist enough evaluated through C/T in
diagnosis spinal string, delicate bandanna wounds also,
support of careful basic leadership viaspinal column
mysterious bony wounds will be talked about. Outlined
specialists, because of its expanded accessibility
belongings are primarily of cervical spine injury, yet
in the crisis settings and its naturally predominant
thoracolumbar backbone wounds are additionally
differentiation goals, M/R/I havebein performance an
integratedsomewhere proper. Different constraints in
undeniably critical job in the administration of
addition to entanglements of M.R.I in spinal injury
spinal
imaging motivation likewise subsist talked about.

Indications of spinal MRI: As indicated by American/

College-of/Radiology-(A/C/R) suitability criterion,
Corresponding Author: M,R,I of spine joined among C*T check is proper in the
SkHasane Ahammad situations of intense spinal injury if:
Research Scholar,
Department of Electronics and Engineering, 1. National/Emergency/X-Radiography/Utilization/
KoneruLakshmaiah Education Foundation, Study-(N/E/X/U/S) otherwise Canadian/Cervical-
Guntur–522 502, India Spine/Rule-(C/C/R) criterion are meetplus there
Email: [email protected] are experimental discoveries of my elopathy.
405 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 405

2. N-E-X-U-S or C-C-R criteria are met along with longitudinal/ligament-(A/L/L), posterior/longitudinal/

there are clinical or else imaging discoveries to ligament-(P/L/L), ligamentum flavum, interspinous
propose ligamentous damage. tendon, supraspinous tendon, along with the apophyseal
3. N.E.X.U.S-or-C.C.R criteria show imaging combinedcontainers6-9. Whereas typical tectorial layer
moreover the precisely shaky spine is foreseen. plusoblique tendon preserve be effectively pictured
on M/R/I, because of absence of difference from
Specialized deliberationsin favor of M*R*I The adjoining tissues, the ordinary alar tendons are hard to
commonplace M/R/I convention on behalf of spinal be envisioned9-10.
damage incorporates sagittal T/1-weighted-(T/1-W) also
T/2-weighted-(T/2-W) turn reverberation groupings, Extra Medullary Hemorrhage also Fluid/Collections:
moreover T/2/weighted/(T/2*W) gradient/recalled/echo- Extradural/hematoma is the popular widely recognized
(G/R/E) series, processed in addition to sagittal heavy kind of additional medullary accumulations in injury
short/tau/inversion/recovery (S/T/I/R) arrangements patients. Subdural/hematoma also sub-arachnoid drain
this methods, just as pivotal T-2/W plus T-2/W GRE are remarkable. Pseudomeningoceles/also/extradural
groupings2-5. T*1/W pictures be fundamentally utilized liquid accumulations because of dural/tear befurther
in support of portrayal of life systems moreover unprecedented sequelae of spinal injury. Despite the fact
bony cracks. As of late, dissemination/tensor/ that CT can demonstrate the different kinds of
imaging (D/T/I) have been utilized to identify injury hematomas in the spinal trench, because of pillar
connectedmodifications in the spinal string which be solidifying antiques in C/T as well asimproved delicate
not seeon ordinary M/R-I procedure. In a perfect world hankie differentiate goals in M-R-I, MR/I is the
MRI ought to be executed inside 72/hours of damage methodology of decision for picturinging of these
as the T/2 hyper-intensity delivered through edema get substances. Epidural/hematomas normally show up
better the conspicuity of the tendons which be viewed as isointense to marginally hyperintense on T/1-W pictures
smallflag power in ordinary state. Afterward on, a goal along with hyperintense on T/2-W pictures. Whole
of the edema plus drain lessens affectability of M*R/I to craniocaudal degree of the hematoma preserve be
identify ligamentous wounds 6-8. effectively assessed on sagittal M/R/I. Like
Normal/Anatomy of the Spine: The backbone epidural/hematomas, subdural/hematoma as well as sub/
essentially comprises of vertebral column balanced arachnoid discharge illustrate accumulations among
out by different tendons together with the anterior/ differing indication powers in the subdural
subarachnoid/ spaces, separately.

Fig. 1: Axial T2 weighted/mage (a) demonstrates the attendance of position traumatic/vertebral blood
vesselanalysisthrough double/lumen (arrow). Following C/T angiogram of the neck (b) verify of the
judgment of vertebral/artery/injury/(arrow). Follow-up/angiography of the necklineperforms on the after
that day (c) explains the occurrence of pseudo aneurysm (arrow).
Vascular Injuries: Vascular wounds container be routes. Albeit asymptomatic one-sided wounds are
brought about by together obtuse also infiltrating injury. of fewerscientific criticalness, they preserve prompt
In dull vascular wounds in the collar, vertebral veins intellectualas well as cerebellar areas of localized
are additional regularly included than carotid supply necrosis, particularly when two-sided. The Denver
viewingcriterionhavebe utilized to recognize the patients Albeit neurological capacity next to the introduction
in danger in favor of vascular wounds also incorporates remainder the absolute greatest prescient aspecton behalf
C1– C3 breaks, crack of the cervical spine stretching out ofextended haul guess, nearness of string discharge have
addicted to a foramen transversarium,/cervical spine/ been depicted as the majority vital discoveries related
subluxation, Le Fort/II before III/facial breaks, basilar/ amongdeprived visualization. Different discoveries
skull support cracks including the carotid trench, of predictive esteem incorporate the degree of string
disperse axonal damage, and extending neckline hematoma as well as rope edema, along with spinal rope
hematoma. In the event of thoracolumbar backbone pressure by additional hub hematoma. Because of
injury, wounds to the aorta moreover its limited spinal trench, osteophytes or clasped
twigscontainerhappen. ligamentum/flavum mightconsequence in wounds to the
focal dim issue together with the focal parts of
corticospinal territory of the cervical/string12.

Pitfalls of MRI: There are couples of confinements of

M/R/I in the assessment of spinal injury. Powerlessness
relics because of metallic equipment for spinal
combination along with dental inserts preserve
corrupt the picture superiority particularly on G/R/E
grouping. Weakness antiquities can be decreased by
utilizing the turn reverberation successions, little T/E
Fig. 2: Sagittal/T/2/weighted/image (a) also axial
which permits fewer instancesin support of dephasing
gradient/recalled/echo/(G/RE) picture (b) proves the
moreover lessens flag misfortune, expansive recipient
occurrence of hemorrhagic/contusion/(arrow, a) in
the spinal/cord/characterized through susceptibility/ transmission capacity, STIR instead of synthetically
artifact on G/R/E image (arrow, b). particular fat concealment, in addition toexchange the
stage programalong with recurrence encode headings.
The imaging discoveries of vascular wounds Immersion beats utilized in MRI can at times cover the
incorporate negligible intimal damage, representation prevertebral hematoma. Liquid in throat and fragmented
of intimal fold pseudoaneurysm (Figure-2b),/ concealment of the prevertebral fat can here and there
dismemberment through intramural/hematoma, absolute recreate prevertebral edema. Conspicuous veins in the
impediment, dynamic extravacation, and arteriovenous interspinous district showing elevated flag on S/T/I/R
fistula arrangement. pictures ought not subsist mistaken for edema related
amid interspinous wounds which show up as badly
Spinal Cord Injuries: Clinically, the degree of spinal
characterized zone of high flag, while the veins show
line damage is characterized through the American/
up too characterized direct territories of high flag. The
Spinal/Injury/Association (A/S/I/A) Impairment/Scale
affectability of M/R/I is additionally inferior than C/T
(which is adjusted commencing the
for recognizing breaks of the back components because
Frankel/arrangement) utilizing the accompanying
of insignificant edema related with separation wounds,
classes: A=Complete– no tactile or engine work is
and to wounds of the craniocervical intersection.
protected in sacral sections S4-
5; B=Incomplete – tangible, however not engine, work
is safeguarded beneath neurologic dimension and Main Work
stretches out from side to side sacral portions S4-5; C = Hemorrhage: The main widely recognized area of
unfinished posttraumatic spinal string drain is the focal dim
– engine work is saved underneath the neurologic matter of the spinal string at the purpose of mechanical
dimension, as well asmainlyinputstrength underneath effect. The injury regularly speaks to hemorrhagic
the neurologic dimension contain a muscle/grade < 3; corruption; genuine hematomyelia is once in a while
D = engine work is saved underneath the neurologic/ experienced. The injury shows up as a discrete focal
dimension, moreovermojority key muscles beneath the point of hypointensity on T2-weighted and slope
neurologic dimension include a muscle/grade ≥ 3; E = reverberation pictures, growing quickly after SCI. Drain
Normal. In M/R/I evaluation of spinal string damage, the
pivotal and sagittal/T/2W/pictures, also T/2*W G/R/E
pictures are especially helpfuls11.
might be recognized in relationship with complete and complete research depended on the prototype of each
fragmented wounds, with location of a center > 4 mm individual so it doesn’t match any other research
long on sagittal pictures regularly characteristic of total proposals/research persons.
neurologic damage.

There is a spectrum of traumatic SCIs from cord/ REFERENCES

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symptoms in adults, who are likely to have underlying imaging for the evaluation of patients with occult
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edema has a potential for neurological recovery, whereas 4. Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea
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SCI. The length of the edema/contusion is directly obtunded patients with blunt trauma: is MR
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Conflict of Interest: Nil resonance imaging of cervical spinal cord injuries:
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Source of Funding: Self
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written is completely self depended which
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Patients Diagnosis Feature Using KNN- MPM
DOI Number: 10.5958/0976-5506.2019.01604.8

Cloud Computing Based Diagnosis for Cancer Detection

Syed Shameem1, Surya Teja S2, Anoop P2, Pavan Kalyan R2, Vijay V2, P. S. Srinivas Babu2
1
Assistant Professor, Department of E.C.E, 2Members of Microelectronics Research Group,
Koneru
Lakshamaiah Educational Foundation, Guntur, India

ABSTRACT
In the Rural Areas the construction/maintenance of cancer testing centre will be difficult. Due to poor
maintenance the results at the testing centres are not accurate. There may be noise in the CT/MRI scan
reports; there is also chance of blur report. To reduce such issues, we are going to use LabVIEW
(Laboratory Virtual Instrumentation Engineering Workbench) a free software. Usually the cancer screening
test includes colonoscopy, mammography and pap test all such tests costs more. Instead of simple CT/MRI
scans softcopies are analysed and processed through LabVIEW software which reduces the cost. In this
paper, Detection and Diagnosis of different types of Cancer is done through image processing techniques
through LabVIEW software. The data that obtained in this process of detection is send to the doctors using
cloud computing for further diagnosis.

Keywords: LabVIEW, colonoscopy, mammography, paptest, cloud

computing.
Introduction The LabVIEW software can be use in different
ways. It can be extended to hardware, where we can
Cancer is a unidentified disease which became one
detect in real time. The proposed idea is to detect the
of the dangerous of all. Cancer cell grows in a multiple
cancer using the CT/MRI scan images and process them
fashion. The cells usually proliferate in human tissues. using LabVIEW 3,4 software to get a clear picture of the
The death rate due to the cancer is growing rapidly due cancer part. Usually the scan report or the microscopic
to no symptoms can be identified for a person who images of test’s may or may not be clear due to
suffers from cancer until one may reach to the higher equipment they use in the testing centers, for getting
stages where it becomes incurable. Detection of different clear picture of the reports they are processed in the
types of cancer is a complex process no one can software. Once the processing is complete then the
identified easily. One may have found having cancer results are sending to the doctor through “cloud
during some other tests for some other reasons. computing”.
Laboratory Virtual Instrumentation Engineering The cloud computing (CC) 1 is a set of network
Workbench is shortly known as LabVIEW, a well- enabled services, QoS guaranteed, personalized and
defined programming environment which is developed inexpensive. These days the cloud services are being
using different programing languages such as C, C++, common, every network, electronics, browsers are
JAVA. But LabVIEW is beyond coding. providing cloud services. There are several cloud
computing technologies such as Artificial Neural
Networks (ANN) 5, Back Proportion Neural Networks
(BPNN) 6

This Neural Networking 7-9 is information

Corresponding Author: processing paradigm. The Neural Networks are example
Syed Shameem of biological system such as human Brain. But the same
Assistant Professor, Department of E.C.E Cloud Computing (CC) can be achieved through IoT
Koneru lakshamaiah educational Foundation (Internet of Things).
Guntur, India
Email: [email protected] IoT is combination of sensors which makes our
environment internet connected. The ESP8266 Wi-Fi
module can create a cloud and send data through it.
410 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 410

Detection of Cancer using Lab VIEW: symptoms stay unknown. When these cancers are in
their earlier stages they start to create solid mass of
Cancer: Cancer is not simply a disease it leads to
cancer cells that grows in a rapid fashion that kills the
different diseases with enormous cell growth. It can start
organ tissues.
in any place of the body and can spread to many other
parts of the human body. Cancer cells grow rapidly and Detection of Cancer Content: In the current
out of control when compared to normal cells. Normal technology LabVIEW provides a best Virtual
cells grow periodically and are worn out after their Instrumentation, in this paper the microscopic or scan
life time, whereas cancer cell form lumps rapidly and images are processed in LabVIEW. There are several
outweigh the normal cells 11 image processing techniques which enhance the
cancer part for the clear idea. Usually any image is
Some cancer types like Lung and gastric have many
made up of pixels, the pixels intensity will be more at
stages where it can’t be identified during early stages but
cancer part. Using image processing techniques such as
by the time it is identified then it will become beyond
thresholding, edge detection, form those techniques we
curable 13
can obtain the edge of the cancer cells (in blood cancer)
Types of Cancer: There are number of cancers which and the cancer mass (in lung cancer) from that we can
can’t be identified in the early stages at which it is clearly detect the presence of cancer in the tissues10
curable 12.
Initially the CT/microscopic image is taken and
Lung Cancer, Bladder Cancer, Blood Cancer/ applied with image processing techniques, due to
Leukemia, Breast Cancer, Pancreatic Cancer, Prostate thresholding less pixel values are washed out if there is
Cancer, Thyroid Cancer, Gastric Cancer, Brain Tumor, any cancer mass then it will be remained in the output
Colon Cancer. These are few of such cancers where image. The entire process is depending on pixel
intensities.

Figure 1: Detection of Cancer using LabVIEW

Figure.1 depicts the construction of cancer detection that purpose the image is changed to array and it passed
VI (Virtual Instrumentation). The microscopic image is through two for loops which convert 2D array to an
fed through read image sub VI and then the image is element which is then inverted and again converted
flow through edge detection and thresholding sub VI’s. array to image using sub VI’s. These three image
Sometimes the X-Ray image may be not visible clearly processing techniques will help to have a clear vision of
but it’s negative may provide adequate information diagnosis perspective 3
for
Methodology composed into a lot of bent line fragments named edges.
A similar issue of discovering discontinuities in one-
The proposed idea is to process the image of
dimensional signs is known as step location and the
microscopic report using image processing techniques
issue of discovering signal discontinuities after some
such as image thresholding, image edge detection and
time is known as change identification. Edge detection is
image negative. All these image processing techniques
a central apparatus in picture preparing, machine vision,
uses pixel manipulation methods. Initially the scan
and PC vision, especially in the regions of highlight
results are converted to grayscale images. Later the
discovery and highlight extraction 2
grayscale image is threshold, where the particular pixels
values are threshold to higher intensity, so all the blood There are different types of edge detection
cells or other content will be faded, and the cancer mass techniques: Roberts Edge Detection, Sobel Edge
will be highlighted. Similarly, in the edge detection Detection, Prewitt Edge Detection, Laplacian Edge
technique the edge of all the objects is obtained, due Detection, Gaussian Filter, High Pass Filter, Low Pass
to this the shape is clearly picturized. Negative of the Filter, Kirsch Edge Detection, Robinson Edge Detection,
image highlights the cancer mass 4 Marr-Hildreth Edge Detection, LoG Edge Detection,
Canny Edge Detection
Later the results which we got in the LabVIEW
are sent to the doctor or any authorized person through Usually all the Edge Detection techniques have
Cloud Computing (CC) using Internet of Things (IoT). their own kernels (3x3 matrix) with which the image is
The ESP8266 Wi-Fi Module helps in achieving Cloud convoluted to get the edge of the image. Some of the
Computing. The person on the other side gets these edge detection kernels elements sum is non-zero which
results, and prescribes medication. results in weighted pixels. Due to that the edges of the
images aren’t perfect enough for few applications such
Thresholding: Thresholding is a process of image as medical fields. Out of all the Edge Detection
segmentation usually used to convert a grayscale image techniques the Canny Edge Detection gives the perfect
to binary (0 or 255). Auto thresholding is a technique edges of the images. In Figure 2 the results of different
where the system itself thresholds lower pixels to 0 and edge detection techniques are given.
higher pixel values to 255. It provides better visibility of Canny Edge Detection: It is the most used edge
cancer mass. Since the cancer mass in gray scale consists detection technique in industrial level applications, the
of more pixel values. There also other types of canny edge detection was introduced by john canny
thresholding like multi band thresholding for colour during his master’s, MIT 1983. The canny edge
images. detection is most precise edge detection technique of all
the other techniques. It is shown clearly in Figure.3

Figure 2: Thresholding of Blood Cancer Cells

Edge Detection: Edge detection incorporates an

assortment of scientific techniques that go for
distinguishing focuses in an advanced picture at which
the picture splendor changes forcefully or, all the more
formally, has discontinuities. The focuses at which
picture brilliance changes forcefully are normally Figure 3: Results of different edge detection
techniques
The filters that are used in canny edge detection cancer. After image processing through LabVIEW its
are exceptionally good at clearing noise from the image been sure that the content which is present along with the
before detecting the edges. The approach of canny edge RBC are cancer cells. After the edge detection the cancer
filtering is central difference. cell content is clearly visible for better clarification the
image is thresholded and obtained the presence of cancer
Here’s the kernel matrix for canny edge
content.
detection
technique.
1 0 1
1 0 1
1 0 1
Kernel matrix of canny edge detector
The mask or kernel is convoluted with the image
such that every pixel of image is multiplied with the
center element of kernel matrix and the final sum will
gives the edge of the image. As the sum of the canny Figure 6: Microscopic image normal blood cells
edge kernel elements is zero there’s no weight in result
image (edge detected image) also it all 1’s the edge In the Figure.6 the edge and threshold images of
detection in manual way is also a bit easy while compare normal blood cells is shown. When we compared the
to the other edge detection techniques. Figure.5 and 6 the excess mass is detected that there is
some extra content.

Figure 4: canny edge detection of blood cells

Figure 7: Detection of lung cancer
Results and Discussions
In this Figure.7 had taken the X-ray of human lungs
and given as input to the LabVIEW, in the edge detection
the image was so many edges so that we can’t predict the
extra mass, but if we see the thresholded part then it is
clear that the lungs having some excess mass in left and
right parts.

Figure 5: Detection of blood cancer cells

The Figure.5 depicts the detection of cancer cells in
the blood, along with the RBC the cancer cells are found
in the microscopic image. But the cancer cells have taken
similar shape of RBC, so it will be difficult to report
the Figure 8: X-ray of Normal Human Lungs
When we compare both Figure 7& 8 then it will be Conflict of Interest: Nil
clear the X- ray report that we have given containing
some excess mass in it. As if it is normal lungs the Source of Funding: Self
threshold image will be plain without any disturbances.
Ethical Clearance: My research article what we have
written is completely self depended which enrolls
complete research depended on the prototype of each
individual so it doesn’t match any other research
proposals/research persons.

REFERENCES
1. Guoyin Zhang, Liang Kou, Ye Yuan, Jianguo
Sun, Yun Lin, Qingan Da, Wenshan Wang, “An
Intelligent method of cancer prediction based on
Figure 9: CT scan of human Abdomen mobile cloud computing”, Springer, 2017
2. Muthukrishnan. R and M. Radha, “Edge Detection
Techniques for Image Segmentation”, IJCSIT,
2011.
3. Meharun nisa S.P, Dr. K. Suresh, “LabVIEW
Implementation of Identification of Eatly Signs of
Breast Cancer”, ICECCE, 2014.
4. Ankit, Sandeep Dahiya, “Detection and
Measurement of Brain Tumor using LabVIEW”,
IJIET, 2016.
Figure 10: CT scan of Internal abdomen 5. Ishwinder Kaur Sandhu, Meera Nair, Ravindra
Prasad Aharwal and Sardul Singh Sandhu
When the CT scan reports of human abdomen are
fed to the system as they are perfect in condition it “Diagnosis of Cancer using Artificial Neural
doesn’t shown any excess content which depicts that the Networks and Cloud Computing Approach”.
logic is working correctly. World Journal Of Pharmacy And Pharmaceutical
Sciences vol. 3. Issue 6, pp.1533-1548. June 2014
Conclusion 6. Vivek Navale, Philip E. Bourne, “Cloud
Computing applications for Biomedical science:
Using the LabVIEW assistance, we can process A Perspective”, 2018.
the X- ray, CT, Microscopic images and can find the
presence of any excess content. Later the results are send 7. Ritesh Anilkumar, Ratandeep, Emmanuel Mark,
to the doctor or any other authorized person for further “Big Data Predective Analysis for Detection of
tests so that the receiver can prescribe the medication prostate cancer on cloud computing platform”,
accordingly. Also, sometimes when a person is affected 2017.
with an accident then there is chance of blood clots in
8. Alex Mu -hsing Kuo, “Opportunities and
some organs. But the LabVIEW will show us that excess
mass, but it may not be cancer content. So, we need to challenges of cloud computing to improve health
make sure of the content which is displaying is belongs care servvices”. March 2015.
to cancer or not. For that purpose, the given image is 9. Azmi Shawkat Abdulbaki, Saif Al-din M. Najim
needed to compare with database of different types of and Samir Abdulrasoul Khadim, “Eczema Disease
cancer. By comparing the pixel values, it can be easily Detection and recognition in cloud computing”,
detected whether the content is of cancer or not. Also, International Journal of Applied Engineering
we can directly display the type of cancer. Also by using
Research, 2017.
this comparison method we can also predict the stages
of cancer. 10. P.Banupriya, G.Kiruthika, S.Kokila, R.Aruna,
T.Radhu, I.Vinodhini, “implementation of liver
cancer using LabVIEW”, 2016.
11. https://www.cancer.net/cancer-types/Cancer.Net 13. https://www.healthline.com/health/lung-cancer,
Editorial Board, 2016. 21 Nov, 2016
12. https://www.cancer.org/cancer/stomach-cancer/
detection-diagnosis-staging/staging.html ,
December 14, 2017
DOI Number: 10.5958/0976-5506.2019.01605.X

A Cross-Sectional Study to Assess the Knowledge about

Prevention and Home Management of Diarrhoea among
the Mothers of Under Five Children in an Urban Area of
Amritsar, Punjab

Amanpreet Kaur1, Harpreet Kaur2, Harpreet Kaur3, Priyanka Devgun4

1
Associate Professor, 2Professor, Department of Community Medicine, Sri Guru Ram Das Institute of
Medical Sciences & Research, Amritsar, Punjab, India; 3Statistician cum Assistant Professor,
Department of Community Medicine, Kalpana Chawla Government Medical College,Karnal, Haryana;
4
Prof. & Head, Department of Community Medicine, Sri Guru Ram Das Institute of Medical Sciences &
Research, Amritsar, Punjab, India

ABSTRACT
Background: Acute diarrhoeal disease is the leading cause of mortality in children worldwide with the
highest burden being in Sub Saharan Africa and in the countries of the World Health Organisation (WHO)
South East Asia Region. In India, diarrhoea is the third leading cause of child mortality in India and is
responsible for 13% of all deaths annually in children under 5 years of age.
Method: A community based cross-sectional study was conducted and total of 400 mothers of under-five
children were interviewed. The mothers were selected by adopting simple random sampling method. A pre-
designed & pre tested questionnaire was used to collect the information. House to house survey was done to
collect the information. Statistical analysis was done by using SPSS 20.0.
Results: Majority of the mothers (72.8%) were in age group of 21-30 years. Out of total 53% knew that
diarrhoea is passage of three or more loose stool in a day. Education status of mother has significant
relation with the knowledge about diarrhoea and its spread (p=.000). 71.8% knew that it can be managed at
home. Out of 400 females 75.7% knew about sugar salt solution can be prepared at home. 73% of the study
participants knew that vaccination can prevent diarrhoea. Role of zinc therapy along with the ORS in
treating diarrhoea was known to only 32% of the study participants.
Conclusions: The study concludes that there is a need of health education for mothers about prevention
and home management of diarrhoea. Timely management at home can prevent deaths from dehydration
caused by diarrhoea. IEC activities should be increased to educate the community about the principles of
environmental hygiene.

Keywords: Diarrhoea, under five, prevention, home

management

Introduction
Acute diarrhoeal disease is the leading cause of
Corresponding Author mortality in children worldwide with the highest burden
Dr Amanpreet Kaur being in Sub Saharan Africa and in the countries of the
#347, Garden Enclave, World Health Organisation (WHO) South East Asia
GT Road Bypass, Amritsar, Punjab Region. Viral diarrhoea is the most common in young
Mobile: 9646311711 children. Rota virus and adenovirus are prevalent in
Email: [email protected] children less than 2 year.1
416 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 416

Most deaths from diarrhoea occur among children Keeping in mind the importance of prevention and
less than 2 years of age living in South Asia and sub- home management of diarrhoea, the present study was
Saharan Africa. Despite this heavy toll, progress is being designed to assess the knowledge about the same among
made. From 2000 to 2016, the total annual number of mothers of under five.
deaths from diarrhoea among children under 5 decreased
by 60 per cent. Many more children could be saved
Material and Method
through basic interventions.2
A community based cross-sectional study was
Diarrhoeal disease is the second leading cause
conducted in the urban field practice area of the
of death in children under five years old. It is both
Department of Community Medicine of SGRD Institute
preventable and treatable. Each year diarrhoea kills
of Medical Sciences and Research, Amritsar. The
around 5,25,000 children under five. A significant
sample size required for the study was calculated as
proportion of diarrhoeal disease can be prevented
through safe drinking-water and adequate sanitation and Z 2 p(1 − p)
hygiene. Globally, there are nearly 1.7 billion cases of n =
d2
childhood diarrhoeal disease every year. Diarrhoea is Where
a leading cause of malnutrition in children under five
n = Sample size
years old.3
p = expected prevalence or proportion
In India, diarrhoea is the third leading cause of d = precision rate
child mortality in India and is responsible for 13% of
Hereby taking
all deaths annually in children under 5 years of age.
Although there has been decline in total deaths from 2.5 Z = 1.96 (approx. = 2, for level of confidence
million in 2001 to 1.5 million in 2012, the proportional of
mortality accounted by the disease still remains high. 95%)
As per NFHS-3 report, 9% of all under-5 children were p = 0.5 (considering knowledge of mothers
reported to be suffering from diarrhoea in the preceding about
2 weeks.4 diarrhoea as 50%)
d = 0.05
A number of interventions have been proposed for
preventing diarrhoea in young children, most of which n = 384
involve measures related to infant feeding practices, So a total of 400 mothers of under-five children
personal hygiene, cleanliness of food, provision of were interviewed during the period from June to August
safe water, safe disposal of faeces, and immunization.
2018. According to the quarterly report there were 1370
An analysis of the effectiveness, feasibility, and cost
under- five children in urban field practice area of
of each proposed intervention has shown that some are
Community Medicine. The mothers were selected by
particularly effective and affordable, whereas others are
adopting simple random sampling method. The mothers
impractical or ineffective, or require further evaluation.5
who gave consent were included in the study. A pre-
Home treatment is an essential part of the correct designed & pre tested questionnaire was used to collect
management of acute diarrhoea. This is because the information. House to house survey was done to
diarrhoea begins at home and children seen at a health collect information about demographic profile,
facility will usually continue to have diarrhoea after knowledge about prevention and home management of
returning home. Children must receive proper treatment diarrhoea. Statistical analysis was done by using SPSS
at home if dehydration and nutritional damage are to 20.0.
be prevented. Mothers who understand home treatment
should begin it before seeking medical care. When Inclusion Criteria: The mothers of under-five who
“early home therapy” is given, dehydration and were willing to participate were included in the study.
nutritional damage can often be prevented.6
Exclusion Criteria: The mothers who didn’t give
consent and those who were not available at the time of
study were excluded from the study.
Results fingers and 76% knew about both the methods of spread.
Education status of mother had significant relation with
A community based cross-sectional study was
the knowledge about diarrhoea and its spread (p=.000).
conducted in the urban field practice area of the
71.8% knew that it can be managed at home. Out
Department of Community Medicine of SGRD Institute of
of Medical Sciences and Research. A total of 400 400 females 75.7% knew about sugar salt solution can
mothers of under-five children were interviewed. Out of be prepared at home. Regarding other home available
400 mothers, 72.8% were in age group of 21-30 fluids 80.7% knew about rice water, 84% knew about
years
yoghurt drink and regarding coconut water 84.3% were
while 14.4% and 12.8% were <20 and >30 years
aware. While about the harmful drinks in diarrhoea
old.
only 23.7% said that carbonated drinks should not be
59.5% of the mothers had one child and 37.2% and 3.3%
given and 22.2% and 28% discouraged packed juice and
had two and three children respectively. Regarding the
sweetened tea respectively (Table 2).
educational status of the mothers 43.7%, 22.5%, 15.8%
and 1.8% were studied up to matric, middle school, On asking about the prevention of diarrhoea, 63.3%
graduation and post graduation respectively. 16.2% of said it can be prevented by not giving bottle feed. All
the mothers were illiterate. 90.2% of the mothers were the participants (100%) knew about the role of clean
housewives and rest (9.8%) were employed. Education drinking water in preventing diarrhoea. Regular hand
profile of the fathers revealed that 51.7% were educated washing, keeping environment clean and giving fresh
up to matric, 20.8% up to graduation, 13.8% up to food as a method of preventing diarrhoea was known to
middle school, 3.5 up to post graduation and 10.2% 91.5%, 95.7% and 90.3% of the participants
were illiterate. Majority of the fathers (71.7%) were respectively.
semiskilled worker, 18.5% were unskilled and 9.8%
were skilled workers. Regarding vaccination 73% of the study participants
knew about that vaccination can prevent diarrhoea, but
It was observed that 53% mothers knew that out of them only 23% knew that measles vaccine can
diarrhoea is passage of three or more loose stool in a prevent diarrhoea. Role of zinc therapy along with the
day. 15% of the respondents said that it spread by ORS in treating diarrhoea was known to only 32% of the
contaminated water and food, 9% said by contaminated study participants.

Table 1: Socio-demographic profile of the respondents

Frequency Percentage
<20 58 14.4
Age in years 20-30 291 72.8
>30 51 12.8
1 238 59.5
No. of children 2 149 37.2
3 13 3.3
Illiterate 65 16.2
Middle school 90 22.5
Education status of mothers Matric 175 43.7
Graduate 63 15.8
Postgraduate 7 1.8
Housewife 361 90.2
Occupation of mother
Employed 39 9.8
Illiterate 41 10.2
Middle school 55 13.8
Education status of husband Matric 207 51.7
Graduate 83 20.8
Postgraduate 14 3.5
Conted…
Unskilled worker 74 18.5
Occupation of father Semi-skilled worker 287 71.7
Skilled worker 39 9.8

Table 2: Knowledge of the mothers about beneficial and harmful fluids in diarrhoea
Fluid Frequency Percentage (%)
Beneficial Fluids
Rice Water 323 80.7
Yoghurt drink 336 84.0
Coconut Water 337 84.3
Sugar salt solution 303 75.7
Harmful fluids (those who said that it should not be given)
Carbonated drink 95 23.7
Packed juice 89 22.2
Sweetened tea 112 28.0

Table 3: Knowledge of the mothers about prevention of diarrhea

Preventive Measures Frequency Percentage
Not giving bottle feed 253 63.3
Clean drinking water 400 100
Hand washing 366 91.5
Clean environment 383 95.7
Fresh food 361 90.3
Vaccination 292 73.0

Discussion and rest (9.8%) were employed. Education profile of the

fathers revealed that 51.7% were educated up to matric,
The study was conducted in the urban field practice
20.8% up to graduation, 13.8% up to middle school, 3.5
area of the Department of Community Medicine of
up to post graduation and 10.2% were illiterate. Majority
SGRD Institute of Medical Sciences and Research.
of the fathers (71.7%) were semiskilled worker, 18.5%
A total of
were unskilled and 9.8% were skilled workers.
400 mothers of under-five children were interviewed.
Majority (72.8%) were in the age group of 21-30 years. It was observed that 53% mothers knew about the
Similarly in a study done in southern Odisha 74% correct definition of diarrhoea. 15% of the respondents
mothers were in age group of 21-30 years.7 59.5% of the said that it spread by contaminated water and food, 9%
mothers had one child and 37.2% and 3.3% had two and said by contaminated fingers and 76% knew about both
three children respectively. Regarding the educational the methods of spread. Education status of mother had
status of the mothers 43.7%, 22.5%, 15.8% and 1.8% significant relation with the knowledge about diarrhoea
were studied up to matric, middle school, graduation and and its spread (p=.000). 71.8% knew that it can be
post graduation respectively. 16.2% of the mothers were managed at home. Out of 400 females 75.7% knew
illiterate. In a study done among mothers in a tertiary about sugar salt solution can be prepared at home.
care hospital it was found that 11.5% of the mothers Regarding other home available fluids 80.7% knew
were illiterate, 51.5% had studied up to high school about rice water,
level and 12.5% were graduates or post-graduates.8 In 84% knew about yoghurt drink, 84.3% coconut water.
the present study 90.2% of the mothers were housewives While about the harmful drinks in diarrhoea only 23.7%
said that carbonated drinks should not be given and contributed to the completion of this proposal in one
22.2% and 28% discouraged packed juice and sweetened way or another.
tea respectively. In another study done among Nigerian
mothers it was found that 22.7% of mothers would use
salt sugar solution (SSS) to treat their children who had
diarrhea, while 9.9% of them would use UNICEF oral
rehydration salt (ORS) for the same purpose.9 Similarly
in a study done in Ethiopia only less than half of the
participants (42.4%) used homemade solution during
diarrheal disease of their child.10

63.3% of the participants said it can be prevented by

not giving bottle feed. All the participants (100%) knew
about the role of clean drinking water in prevention of
diarrhoea. Regular hand washing, keeping environment
clean and giving fresh food as a method of preventing
diarrhoea was known to 91.5%, 95.7% and 90.3% of the
participants respectively. In a study done in
Karnatka
68% of the participants had knowledge about
the
preventive measures of diarrhoea.11

Regarding vaccination 73% of the study participants

knew about that vaccination can prevent diarrhoea, but
out of them only 23% knew that measles vaccine can
prevent diarrhoea. Role of zinc therapy with the ORS in
treating diarrhoea was known to only 32% of the study
participants Knowledge about the zinc therapy was
significantly assoiciated with the educational status of
mother (p=.003). Similar findings were there in a study
done by Ogunrinde et al.12

Conclusions

The level of knowledge of the mothers of under five

regarding the prevention of diarrhea was found to be
good but the home available fluids given in diarrhea
were not known by many of the participants. Efforts
should be made to educate the mothers about the home
management of diarrhoea. IEC activities should be
strengthened to educate the community about prevention
of diarrhoea. Other preventive measures like
environment sanitation, hand hygiene, vaccination
should also be taught to the mothers and rest of the
community.

Acknowledgement

We would like to thank the faculty of the

Department of Community Medicine for their valuable
suggestions. We would also like to thank the mothers
who participated in the study and to all those who
Conflict of Interest: None declared

Source of Funding: None

Ethical Clearance: The study was approved by the

institutional ethics committee.

REFERENCES
1. Kadri AM,Epidemiology of Acite Diarrheal
diseases and its prevention and control. IAPSM’s
Textbook of Community Medicine. 1st edition,
2019:373
2. Diarrhoeal disease, UNICEF. Available at: https://
data.unicef.org/topic/child-health/diarrhoeal-
disease/
3. Diarrhoeal disease, WHO. Available at: https://
www.who.int/en/news-room/fact-sheets/detail/
diarrhoeal-disease
4. Bhalwar R, Dudeja P, Jindal AK. Acute
Gastoenteritis, Communicable Diseases. Textbook
of Community Medicine. 2nd edition. 2018:571
5. UNIT 8 - Prevention of Diarrhoea, Medical
Education: Teaching Medical Students about
Diarrhoeal Diseases. Available at: https://
rehydrate.org/diarrhoea/tmsdd/8med.htm
6. Unit 4 - Treatment of Diarrhoea at Home
Medical Education: Teaching Medical Students
about Diarrhoeal Diseases. Available at: https://
rehydrate.org/diarrhoea/tmsdd/4med.htm
7. Padhy S, Sethi RK, Behera N. Mother’s
knowledge, attitude and practice regarding
prevention and management of diarrhoea in
children in Southern Odisha. Int J Contemp
Pediatr. 2017 May;4(3):966-971
8. Ashraf A, Bhat MA, Mahrukh. Childhood
diarrhoea: assessment of knowledge, attitude and
practices among mothers attending the tertiary care
hospital – an observational analytical study. Int J
Community Med Public Health 2017;4:1219-22.
9. Adimora GN, Ikefuna AN, Ilechukwu G.
Home management of childhood diarrhoea:
Need to intensify campaign. Niger J Clin
Pract
2011;14:237-41.
10. Workie HM, Sharifabdilahi AS and Addis EM.
Mothers’ knowledge, attitude and practice towards
the prevention and home-based management
of diarrheal disease among under-five children 12. Ogunrinde OG, Raji T, Owolabi OA, and Anigo
in Diredawa, Eastern Ethiopia, 2016: a cross- KM Knowledge, Attitude and Practice of Home
sectional study. BMC Pediatrics,2018;18:1-9. Management of Childhood Diarrhoea among
11. Gollar LH, Avabratha KS. Knowledge, attitude, Caregivers of Under-5 Children with Diarrhoeal
and practice of mothers of underfive children Disease in Northwestern Nigeria. Journal of
regarding diarrheal illness: A study from coastal Tropical Pediatrics,2012;58(2):143-6.
Karnataka. Muller J Med Sci Res 2018;9:66-70.
DOI Number: 10.5958/0976-5506.2019.01606.1

A Study to Assess the Parents Satisfaction Regarding Pediatric

Care Services Rendered by Staff Nurses from Selected
Pediatric Units of Sangi City

Karishma D. Mulla1, Aparna Kale2

1
M.Sc Nursing, 2Assistant Professor, College of Nursing, Bharati Vidyapeeth (Deemed to be University),
Sangli

ABSTRACT
A quantitative study was conducted by Ms. Karishma Mulla. out with the purpose of to know the parents
satisfaction level towards pediatric care which rendered by staff nurses in the hospital.
Aims of the Study :
1. To assess the satisfaction level of parents regarding pediatric care services.
2. To find out association between satisfaction score and selected demographic variables.
Materials and Method: This study based on quantitative approach and it is a non – experimental
descriptive research design was used to assess the parent satisfaction regarding paediatric care rendered by
staff nurses from pediatric units of sangli city. Total 110 samples were selected by simple random
sampling technique. A likert scale of five domains which includes 30 items were administer to collect
data. The reliability coefficient was found to be ‘r’ value is 0.8 which is more than 0.7 hence, the tool was
found to be reliable. The conceptual framework based on the Jean Watson human caring theory.
Result: The result of the parents satisfaction level regarding towards pediatric care were found 98.18%
parents are highly satisfied, and 1.82 % of parents were moderately satisfied with the pediatric care which
is rendered by staff nurses in the pediatric unit.
As per the domain, The satisfaction level of parents was found towards the environment 94.55 %,
information
94.55 %, communication 96.36 %, nursing care 95.45 %, recreation 83.64 %.
This result shows the parents are highly satisfied towards the pediatric care rendered by staff nurses in the
pediatric unit.

Keywords: Assess, Parents,

satisfaction.
Introduction parental satisfaction towards the pediatric care which
is given by the staff nurses or health (taken) while
Now a days more competition occurs in the
maintaining a higher level of parents satisfy of child’s
organization to improve the standard of care as a means
care than ever before. The everyday care is improved
to determine particular health care facilities provision
and time and time period recognize as when parental
auxillaryl portion of the pediatric health care they
satisfaction requirements should be fulfillment of care
are very achieve with higher parental predisposition
it include the word environment receiving the proper
for child care. As a result of wards need to check
information about ward, staff, and care of child, open
the
communication, flexible nursing care and also recreation
or entertainment for the children.2
Corresponding Author: Parents after determine satisfaction of care given
Dr. Mrs. Aparna Kale to the children by analyzing the attitudes of staff nurses
Assistant Professor, College of Nursing, and another health care team. Every hospital incidents
Bharati Vidyapeeth (Deemed to be University), Sangli is special to each and every individual and depends
Email: [email protected] on
422 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 422

other elements. Children are unable to express their improvement in quality of cares, managers and planners
needs. So parents to interpret their needs. Assess quality of health care system are much more interested. It is
of services on the basis of level of parental satisfaction clear out evaluation of present state and designing for
is essential to an important outcome issue. further development. This one of the crucial factor an
affect on standards of health care services. To improve
Now a days however evaluation and notice the the quality of health care services, assessment of parents
deficiency and standard of intelligibility to the optimum satisfaction level is one of the indicator. Determining the
health services as the crucial concern of the guideline level of health services the researchers believe this one
makers in health globally. As a result now a days of the important factor

Findings

Section I: Frequency and Percetage Distribution of Demographic Variables

Table 1: Frequency and percentage distribution of demographic variables

Sr. No. Variables Groups Frequency Percentage (%)
1. 18-24 48 43.64
Age in years 25-31 61 55.45
32-38 1 0.91
2. Illiterate 11 10.00
Primary 27 24.55
Secondary 33 30.00
Education
Higher secondary 16 14.55
Graduation 14 12.73
Post graduation 9
3. Housewife 72 65.45
Occupation Service 25 22.73
Business 13
4. 5000-10000 20 18.18
Monthly Income in 10001-20000 55 50.00
rupees 20001-30000 26 23.64
above 30000 9 8.18

Section II: Assessment of level of parents satisfaction as per domain

Table 2: Assessment of level of parents satisfaction as per domain

N = 110
Sr. No. Domains Groups Score Frequency Percentage %
Dissatisfied 06-10 01 0.91
1. Ward Environment Moderately Satisfied 11-14 05 4.55
Highly Satisfied 15-18 104 94.55
Moderately Satisfied 11-14 06 5.45
2. Information
Highly Satisfied 15-18 104 94.55
Moderately Satisfied 11-14 04 3.64
3. Communication
Highly Satisfied 15-18 106 96.36
Conted…
Moderately Satisfied 11-14 05 4.55
4. Nurse Care
Highly Satisfied 15-18 105 95.45
Dissatisfied 06-10 03 2.73
5. Recreation Moderately Satisfied 11-14 15 13.64
Highly Satisfied 15-18 92 83.64
In the ward environment domain there were 94.55% In the nursing care domain were 95.45 % parents
parents were highly satisfied with the ward environment are highly satisfied with the nursing care and 4.55 %
and 4.55 % of parents were moderately satisfied with were moderately satisfied with nursing care, hence result
ward environments, hence result found is parents are found that parents are highly satisfied with nursing care
satisfied with ward environment which is provided by
which was provided by the staff nurses.
staff nurses.
In the recreation domain 83.64 % parents were
In the information domain there were 94.55% parents
highly satisfied with the recreation and 13.64 % of
were highly satisfied with the information 5.45 % were
parents were moderately satisfied, hence result found
moderately satisfied with information, hence result found
parents was highly satisfied with recreation which is
is parents are highly satisfied with information which is
provided by the staff nurses in the pediatric unit.
provided by staff nurses related to children’s health.
Section III: Assessment of satisfaction Level of
In the communication domain were 96.36 %
Parents
parents were highly satisfied with the communication
and were 3.64 % of parents moderately satisfied with Deals with analysis of data related to assessment
communication, hence result found that parents are the level of parents’ satisfaction regarding pediatric care
highly satisfied with communication of the staff nurses. services, in terms of frequency and percentage
Table 3: Satisfaction level of the parents’ regarding pediatric care services
N = 110
Groups Score Frequency Percentage (%)
Moderately Satisfied 50-70 2 1.82
Satisfaction
Highly Satisfied 70-90 108 98.18
Total 110 100.00

The above table no. 3 shows the satisfaction level of the parents regarding pediatric care services, such a that
98.18% of parents were highly satisfied with their experience about hospital services, 1.82% parents were
moderately
satisfied. No one was in dissatisfied category.

Figure 1: Level of parents’ satisfaction regarding pediatric care services

Section IV: Analysis of data related to the association between satisfaction score and selected demographic
variables

Table 4: Association between satisfaction score and selected demographic variables

N = 110
Satisfaction
Sr. Chi p
Variables Groups Moderately Highly d. f. Significance
No. Square value
Satisfied Satisfied
18-24 2 46
Not
1 Age 25-31 0 61 2.63 2 0.27
Significant
32-38 0 1
Illiterate 0 11
Primary 1 26
Secondary 0 33 Not
2 Education 3.53 5 0.62
Higher secondary 1 15 Significant
Graduation 0 14
Post graduation 0 9
Housewife 0 72
3 Occupation Service 0 25 15.19 2 0.00 Significant
Business 2 11
5000-10000 0 18
Monthly 10001-20000 0 55
4 9.16 3 0.03 Significant
Income 20001-30000 0 26
above 30000 9
Age and Satisfaction: The p value of the association satisfaction was 0.03, less than 0.05. Concludes that,
test between age and parent satisfaction was 0.27 which there was significant association between monthly
is, more than 0.05. Concludes that, there was no income of parents and their satisfaction about paediatric
significant association between age of parents and their care services
satisfaction about paediatric care services which is
rendered by staff nurses in the paediatric units. Discussion
Education and Satisfaction: The p value of the Section I: Analysis of demographic data in terms
association test between education and parent of
satisfaction was 0.62, more than 0.05. Concludes that, frequency and percentage distribution
there was no significant association between education
of parents and their satisfaction about paediatric care 1. Age: In this study according to age of parents,
services which was rendered by staff nurses in the most of parents 55-45% were between 25-31
paediatric units. years of age group, 43.64% were 18-24 years of
age, 0.91% between 32-38 years, hence maximum
Occupation and Satisfaction: The p value of the parents were 25-31 years of age group.
association test between occupation and parent
2. Education: In the study according to education
satisfaction was 0.00, less than 0.05 Concludes that, there
of parents, most of them 30% were educated
was significant association between education of parents
and their satisfaction about paediatric care services which secondary, 24.55% were up to primary, 14.55%
was rendered by staff nurses in the paediatric units. up to higher secondary, 12.73% graduates, 10%
illiterate and 8.18% were educated up to post
Monthly Income and Satisfaction: The p value of the graduation, hence it observed that maximum were
association test between monthly income and parent educated up to secondary education.
3. Occupation: In the study according to occupation and pain management in a paediatric unit. High
of parents, most of them 65.45% were satisfaction rating on the communication item.12
housewives,
22.73% doing services, and only 11.82% in the
business category, hence the maximum parents
occupation 65.45% were housewife category.
4. Monthly Income: in the study according to
monthly income of parents, most of them 50%
from the income group 10001-20000, 23.64%
in the
20001-30000 income group, 18.18% from 5000-
10000 and only 8.18% in the income group above
30000 per month, hence the maximum
monthly
family income was between 10001-20000/-.

Section II: Assessment the satisfaction level of parents

regarding paediatric care as pr domain

Environment: Assessment of the satisfaction about

environment in the hospital of the parents of 1-3 years
children’s at selected paediatric hospitals shows, 94.55%
of parents were highly satisfied with their experience
about hospital environment, 4.55% parents were
moderately satisfied and 0.91% in the dissatisfied
category.

Similar study result reported by Victoria S. Koontz

in year 2003, A descriptive study was conducted in
USA. To assess the parental satisfaction in a paediatric
ICU. The parental satisfaction survey measured 3
domains of caring (a) hospital environment (b) patients
care (c) communication. The results of this study found
very highly satisfied for ICU environment the p value is
less than 0.01.1

Information: Assessment of the satisfaction about

information provided in the hospital of the parents
of 1-3 years children’s at selected paediatric hospitals
shows, 94.55% of parents were highly satisfied with
their experience about information, 5.55% parents were
moderately satisfied

Communication: Assessment of the satisfaction about

communication service provided in the hospital of the
parents of 1-3 years children’s at selected paediatric
hospitals shows, 96.36% of parents were highly satisfied
with their experience about communication, 3.64%
parents were moderately satisfied.

Similar study result reported by Hongs and Susan S.

in years 2008. a pre experimental research conducted in
USA. Parental satisfaction with nurses communication
Nursing Care: Assessment of the satisfaction about
nursing care service provided in the hospital of the
parents of 1-3 years children’s at selected pediatric
hospitals shows, 95.45% of parents were highly satisfied
with their experience about nursing care, 4.55% parents
were moderately satisfied.

Similar study result reported by Naiire salmani et.al.

2015. A Grounded theory study conducted in Yazd, Iran.
The process of satisfaction with nursing care in parents
of hospitalized children. Sample size was 25 consisted
of parents of children. They are used in-depth semi-
structured interviews. The result founds parents are
satisfied with the nursing care.13

Recreation: Assessment of the satisfaction about

recreation in the hospital of the parents of 1-3 years
children’s at selected pediatric hospitals shows, 83.64%
of parents were highly satisfied with their experience
about hospital recreation, 13.64% parents were
moderately satisfied and 2.73% in the dissatisfied
category.

Section III: Deals with analysis of data related to the

association between satisfaction score and selected
demographic variables

Age and Satisfaction: The p value of the association

test between age and parent satisfaction was 0.27, more
than 0.05. Concludes that, there was no significant
association between age of parents and their satisfaction
about pediatric care services.

Education and Satisfaction: The p value of the

association test between education and parent
satisfaction was 0.62, more than 0.05. Concludes that,
there was no significant association between education
of parents and their satisfaction about paediatric care
services.

Occupation and Satisfaction: The p value of the

association test between occupation and parent
satisfaction was 0.00, less than 0.05. Concludes that,
there was significant association between education of
parents and their satisfaction about paediatric care
services.

Conclusion
In this study results found over all satisfaction of
the parents out of the 100 % the 98.18 % of parents
were highly satisfied, and 1.82 % of parents were
moderately satisfied their experience about the care
services in the pediatric unit. Parents were getting clean
ward environment adequate information about the child 4. Suresh k., Pawan k. patient satisfaction with
health, staff nurses communication is also good, meeting nursing care in public and private hospital,
all nursing care their children’s, only in the recreation nursing and midwifery research journal- 2013
the parents were moderately satisfied. july, vol-
9,no.3, p-130-141.
Conflict of Interest: Column is Nil.
5. Erling S., Adrew M. G., parent experience of
Source of Funding: Self. inpatient pediatric care in relation to health care
delivery and socio demographic characteristics,
Ethical Cearance: Proposal of research with the data
BMC health services Reseach 2013,vol-13;p512.
collection tool was presented in the front of research
committee for approval. prior permission from hospital 6. Cenita J. Pavai A. T. Surya, Parental satisfaction
and child development officer, were taken. Informed with pediatric day care surgery and its
written consent from each participant was taken. Which Determinants in a tertiary care hospital, Journal
included name, number, organization, time duration of Indian Associate pediatric surgery 2017, Oct-Dec,
participation, termination of participation, purpose of the vol- 22, issue(4): p226-231.
study, incentives, benefits, and where it was promised
7. S. Aslanabadi, SH Shahbazi, 2014., Mothers
that there will be no risk to the clients. Principle of
satisfaction with Nursing care in a children’s
confidentiality was attained by giving code number to
hospital, International Journal of Nursing 2014,
data collection tool. The received information also kept
vol-26 issue-(86): p61-70.
confidential. Ethical clearance is done with the committee
members Dr. Sripriya G. and Dr. Mrs. Nilima Bhore 8. Jos M. L., Johannes B., Marcel, perception of
parents on satisfaction with care in the pediatric
REFERENCE intensive care unit., Intensive Care Med.,
(2009)
1. Vasiliki M., Barbara B.,Anthi C., Theodora M. 35 : p1082-1089.
et.alparents satisfaction concerning their child’s
hospital care, Japan Journal of Nursing Science 9. Hong, Susan S. Murphy et.al., Parental
(2011-Dec), vol-8 issue-2,p163-173. Satisfaction with nurses communication and pain
management in a pediatric unit, pediatric nursing,
2. Ahmad A Emad Y., Somaie heidari,et.al, July/aug 2008, vol.34 issue4, p289-293.
Outpatient and Inpatient services satisfaction in
Iranian Military Hospitals, Iran Red Cresent Med. 10. kale a, pitre s. Effect of music therapy on selected
Journal, 2013 Sep ; vol-15, issue(9): p843-847. physiological parameters among the premature
babies, wjpr, 2016, vol.5 issue 12,p348-356.
3. Berna erenf, filiz A., kursat F.et al., Parents
expectations and satisfaction of pediatric clinic, 11. Aparna Kale, A Study to assess the effectiveness
Trans. Med (sunnayvale) vol-4 issue-4,year of planned teaching programme related to home
2014p137. care of acute lymphocytic leukemia (ALL) on
knowledge among caregivers of children receiving
chemotherapy, IJNR, 2016, vol-2,issue(3), p128-
134.
DOI Number: 10.5958/0976-5506.2019.01607.3

Effect of Depression on Treatment Outcome in Multi- Drug

Resistant Tuberculosis Patients Under Programmatic
Management of Drug Resistant TB Services in Amritsar,
Punjab

Manisha Nagpal1, Naresh Chawla2, Priyanka Devgun3

1
Associate Professor, Department of Community Medicine, Sri Guru Ram Das Institute of Medical
Sciences and Research, Sri Amritsar; 2MD Chest and TB, District TB Officer, Amritsar; 3Professor
and Head, Department of Community Medicine, Sri Guru Ram Das Institute of Medical Sciences and
Research, Sri Amritsar

ABSTRACT
Background: Depression and Multi-drug resistant tuberculosis (MDR-TB) are worldwide public health
problems with an immense impact on human health. Depression leads to poor health seeking behaviour and
poor compliance which leads to unfavourable treatment outcomes.
Method: This cross-sectional study was conducted on all MDR-TB patients who were registered and being
treated under PMDT services in Amritsar district from 1st April 2014 to 31st March 2015. The prevalence
of depression and its effect on the treatment outcome was determined. Data management and analysis was
done by using Microsoft excel and SPSS.
Results: Out of 87 MDR-TB patients, 57 (65.5%) were males and 30 (34.4%) were females. Depression
was
significantly associated with the unfavourable treatment outcomes.
Conclusions: On statistical analysis, it was observed that 50.6% of the patients were depressed
and
unfavourable outcome was significantly associated with depression (p=0.005) in MDR-TB patients.

Keywords: MDR-TB, Depression, Treatment outcomes, Socio-demographic

factors.

Introduction Email: [email protected]

Multidrug-resistant tuberculosis (MDR-TB) is a

major public health challenge in the twenty-first century.
The World Health Organization (WHO) defines MDR-
TB as TB that is resistant to two first-line drugs i.e.
isoniazid and rifampicin. Worldwide the cure rate is
only around 50% in MDR-TB programme settings.1
The estimated prevalence of mental disorders, including
depression among people with TB is between 40% and

Corresponding Author:
Dr. Manisha Nagpal
Associate Professor, Department of Community
Medicine, Sri Guru Ram Das Institute of Medical
Sciences and Research, Amritsar, Punjab, India
Phone: 9855554545
70%. This is due to various underlying factors. Patients
with mental disorders are at an increased risk of TB
exposure due to higher rates of homelessness which
leads to their residence in other shelters and group
homes. These patients also carry other risk factors for
TB like smoking, poor nutrition and co-morbidities such
as diabetes and HIV infection.2

Depression is considered as a comorbidity of

tuberculosis due to the nature of tuberculosis infection,
side effects from medications, and other social
determinants of health. Depressed patients are less likely
to seek treatment or take their medications regularly
which results in more cases of default, failure or death.
Therefore, depression could be considered as a
concerning exacerbating factor in a potential MDR-TB
epidemic.3

Psychiatric problems such as depression has a

significant role to play in patient’s quality of life and it
also affects the physician’s approach toward MDR-
TB
428 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 428

therapy. Therefore, effective management of depression Data Collection and Analysis: A total of 87 patients
is a key for not only the desired patient outcome, but registered with DTC (District Tuberculosis Centre)
also for patient’s overall quality of health and
Amritsar and being treated with second line anti TB
physician’s satisfaction while dealing with MDR-TB
drugs were included in the study. A pre-designed and
treatment. 4
pre – tested proforma was administered to the subjects
Since there is paucity of such studies in Punjab, the after taking his/her consent. Questionnaire included
study was undertaken to ascertain the effect of questions regarding the socio-demographic profile,
depression in MDR-TB patients on their treatment past history, past duration of treatment, family history
outcomes.
and occupational history of the patients. The possible
outcomes of the MDR TB patients under DOTS can be:
Material and Method
cured, treatment completed, died, failure, defaulted, lost
The study was a cross-sectional study conducted to follow up or regimen changed/shifted to XDR.5
on
all MDR-TB patients registered from 1st April 2014 Depression was assessed in the study subjects by
to CES-D-R 10 (Assessment of depression by Centre for
31st March 2015 and being treated with second line anti-
Epidemiologic Studies Short Depression Scale during
tuberculosis drugs under PMDT services in Amritsar the first 4 months of starting the treatment. This scale is
City. a self-report measure of depression containing 10 items.
Inclusion Criteria: All drug sensitivity tested (DST) The reliability and validity of the scale has been
confirmed MDR-TB cases who signed written informed assessed by various authors. The 10 items are-
consent.

Exclusion Criteria: Pregnant females and critically ill

patients who needed management in an Intensive Care
Unit (ICU).

Rarely or Some or Occasionally or All of

none of the a little of a moderate the time
CES-D-R 10 items
time (less the time amount of time (5-7
than 1 days) (1-2 days) (3-4 days) days)
I was bothered by things that usually don’t bother me.
I had trouble keeping my mind on what I was doing.
I felt depressed.
I felt that everything I did was an effort.
I felt hopeful about the future.
I felt fearful.
My sleep was restless.
I was happy.
I felt lonely.
I could not “ get going”

Scoring
Rarely or none of Occasionally or a
Some or a little of All of the time
the time (less than moderate amount
the time (1-2 days) (5-7 days)
1 days) of time (3-4 days)
Questions 5-8 3 2 1 0
All other Questions 0 1 2 3
The total score is calculated by finding the sum of 10 items. Do not score the form if more than 2
items are
missing. Any score equal to or above 10 is considered depressed.6
429 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 429
Depression was compared with the treatment outcomes of the study patients and the valid conclusions drawn.
Data analysis was done by SPSS version 20. Chi-square test was applied to prove their statistical significance and
p<0.05 was considered to be significant.
Ethics: The research proposal was approved by the Conted…
college ethical committee at the time of commencement Below Matric 19 21.8
of the study. No schooling 22 25.3
*Occupation
Results IGA 63 72.4
Non-IGA 24 27.6
The present study was carried out on 87 MDR- TB
Socio-economic status
cases registered under PMDT services in Amritsar city.
High 5 5.7
The total sample consisted of 57 (65.5%) males and 30 Upper middle 21 24.1
(34.4%) females. Lower middle 43 49.4
Table 1: Distribution of cases according to their Low 18 20.7
Socio-demographic profile
*IGA- Income generating activity; Non-IGA- Non
Number Percentage (%) income generating activity.
Age (years)
Table 1 reveals that majority (43.7%) of the patients
15-29 38 43.7
were in the younger age group i.e. 15-29 years followed
30-44 23 26.4
by 26.4% each in the age groups of 30-44 years
45-59 23 26.4 and
>60 3 3.4 45-59 years. Majority i.e. 65.5% were males. 57.5%
Sex of the cases were married, 32.2% were single and
Male 57 65.5 10.3% were in the category of widow/widower. As far
Female 30 34.5 as educational status is concerned, 26.4% each were
Marital status above matric and matric, 21.8% were below matric
Married 50 57.5 and 25.3% were illiterate. Out of the total 87
Single 28 32.2 patients,
Widow/Widower 9 10.3 72.4% were involved in income generating activities
Education and rest i.e. 27.6% were unemployed. As far as socio-
Above Matric 23 26.4 economic status is concerned, 49.4% were in the lower
Matric 23 26.4 middle status, 24.1% in the upper middle status, 20.7%
belonged to low status and only 5.7% were from the
high socio-economic status.

Table 2: Distribution of cases according to CES-D-R 10 scale

Rarely or Some or Occasionally
All of the
none of the a little of or a moderate
S. time (5-7
*CES-D-R 10 items time (less the time amount of
No. days)
than 1 day) (1-2 days) time (3-4 days)
N (%)
N (%) N (%) N (%)
1. I was bothered by things that usually don’t bother me. 31 (35.6) 35 (40.2) 15 (17.2) 6 (6.9)
2. I had trouble keeping my mind on what I was doing. 35 (40.2) 33 (37.9) 13 (14.9) 6 (6.9)
3. I felt depressed. 29 (33.3) 43 (49.4) 14 (16.1) 1 (1.1)
4. I felt that everything I did was an effort. 30 (34.5) 35 (40.2) 17 (19.5) 5 (5.7)
5. I felt hopeful about the future. 3 (3.4) 13 (14.9) 64 (73.6) 7 (8)
6. I felt fearful. 2 (2.3) 11 (12.6) 65 (74.7) 9 (10.4)
7. My sleep was restless. 1 (1.1) 14 (16.1) 60 (69.0) 12 (13.8)
8. I was happy. 1(1.1) 3 (3.4) 48 (55.2) 35 (40.2)
9. I felt lonely. 20 (23.0)) 53 (60.9) 9 (10.8) 5 (5.7)
10. I could not “ get going” 24 (27.6) 50 (57.5) 12 (13.8) 1 (1.1)
*Scoring of items done as explained in Materials and methods.
Table 2 shows that out of the total 87 patients, 40.2% It is observed in the table 4 that 60% of the cured
were bothered about things that usually don’t bother for patients and 73.7% of the patients who completed
some time i.e.1-2 days per week, 40.2% rarely (<1 day) treatment were not depressed i.e. depression was less
had trouble keeping in mind things they were doing, common in patients with favourable outcome. At the
49.4% felt depressed for some time, 40.8% think that same time 53.8% of the patients who defaulted, 66.7%
they did things with effort for some time, 73.4% were of subjects with outcome as failure, 50% of who shifted
hopeful about their future for moderate amount of time, to XDR regime and 88% of the patients who died were
at the same time 74.7% felt fearful also for 3-4 days or depressed. This means that depression was more seen in
moderate amount of time, 69% had restless sleep for patients with unfavourable treatment outcome and the
moderate time, at the same time 55.2% were happy for results were found to be statistically significant (p-0.005).
the same period,
60.9% felt lonely for some time and 57.5% said that they Discussion
could not “get going” for some time per week.
Table 1 shows the socio-demographic profile of the
Table 3: Distribution of cases according to their patients. Our study reveals that out of the total, majority
treatment outcome i.e. 43.7% were less than 30 years and 52.8% of the
patients were in the age group of 30-59 years which
*Treatment Outcome Number Percentage (%) includes the economically productive age group. Kumar
Cured 30 34.5 A et al in their study also showed that majority (63.1%)
Treatment Completed 19 21.8 were less than 30 years. 7 Studies by Hire et al and Nair
Defaulted 13 14.9 et al in Nagpur and Chennai respectively also observed
that more than half of the patients belonged to
Failure 3 3.5
economically
Shifted to XDR 4 4.6 productive age group. 8,9 Present study observed that
Died 18 20.7 out of total 87 patients, 57 (65.5%) were males and 30
Total 87 100 (34.5%) were females. Similar over representation of
*Favourable outcome included Cured and males was found by Kumar A et al 7 and Thiruvalluvan
Treatment completed; Unfavourable outcome included E et al 10 in their studies. Our study revealed that 57.5%
Defaulted, Failure, Shifted to XDR and Died patients. were married, 47.1% were below matric, 72.4% were
working (IGA) and 49.4% and 20.7% belonged to lower
The perusal of table 3 depicts the treatment outcome
middle class and lower class respectively. Somewhat
of the study subjects. Out of the total 87 patients, 30 similar findings were observed by Thiruvalluvan E
(34.5%) were cured, 19 (21.8) completed treatment, et al in Chennai that 78% were married, 36% had
18 (20.7%) died, 13 (14.9%) defaulted, 4 (4.6%) education level below secondary school and 76% were
were
involved in income generating activities. 10 Bhatt G et
shifted to XDR regime and 3 (3.5%) were failure. al in Ahmedabad city along with the similar findings
observed that majority belonged to upper lower socio-
Table 4: Distribution of cases showing the effect of economic status. 11
depression on the treatment outcome
Table 2 depicts the distribution of cases according
Depression to CES-D-R 10 depression scale. It is evident from our
Treatment
Present Absent Significance study that more than half (50’6%) of the study patients
Outcome
N (%) N (%) were depressed according to CES-D-R 10 scale
Cured 12 (40.0) 18 (60.0) (Table
Treatment 4). 40.2 % were bothered by things and had trouble
5 (26.3) 14 (73.7) keeping things in mind. 49.4% felt depressed and 74.7%
Completed
Default 7 (53.8) 6 (46.2) χ2=16.753 were fearful. 69% had restless sleep occasionally
df=5; and
Failure 2 (66.7) 1 (33.3)
p=0.005 60.9% felt lonely sometimes. Similar association of
ST XDR 2 (50.0) 2 (50.0)
depression with the chronic illness like MDR-TB has
Died 16 (88.9) 2 (11.1) been observed by KM de Castro-Silva et al 12, Jawad K
Total 43 (50.6) 44 (49.4) et al 13, Das M et al 14 and Sharma RC et al 15 in their
studies at various places.
Table 3 presents the treatment outcome of the study 3. Lee, Esther, “Prevalence of Depression among
patients. Favourable outcome was seen in 56.3% cases Active TB and TB/HIV Patients in Kisumu
i.e. cured (34.5%) and treatment completed (21.8%) County” (2015). Independent Study Project (ISP)
cases. Unfavourable outcome was observed in 43.7% Collection. 2152. Assessed on 23rd June 2019.
cases comprising of defaulted (14.9%), failure (3.5%), Available at https://digitalcollections.sit.edu/isp_
shifted to XDR (4.6%) and died (20.7%) cases. Similar, collection/2152.
treatment success rates 62% and 68.3% and other
outcomes were seen in studies in Portugal and China 4. Pachi A, Bratis D, Moussas G, Tselebis A (2013)
respectively. 16,17 Psychiatric morbidity and other factors affecting
treatment adherence in pulmonary tuberculosis
As is evident from the table 4 that out of the patients. Tuberc Res Treat. 2013: 489865.
total
87 patients, 43 (50.6%) were depressed and 44 (49.4%) 5. Guidelines on Programmatic Management of
were not depressed according to CES-D-R 10 scale.
60% of the cured and 73.7% of the treatment completed Drug Resistant TB in India. Central TB Division,
patients were not depressed while 88.9% of the died, Directorate General of Health Services, Ministry
66.7% of failure, 53.8% of the defaulted and 50% of of Health & Family Welfare, Government of
those shifted to XDR regime were found depressed India, New Delhi, 2017.
i.e. depression was significantly associated with the
6. Assessed on 20th June 2019. Available at https://
unfavourable treatment outcomes (p=.005). Similarly,
Ugarte-Gil C in their study on TB patients found that www.brandeis.edu/roybal/docs/CESD-10 _
major depressive episodes is significantly associated website_PDF.pdf.
with negative outcomes. 18 Another study by Ambaw 7. Kumar A, Chaudhari D, Anand R, Verma SK,
F also stated that untreated depression in people with Kumar A, Chaudhry S. Occurrence of psychiatric
tuberculosis was independently associated with worse disorders in the patients of multi drug resistant
treatment outcomes. 19 tuberculosis under treatment. Int J Res Med
Sci.
2018;6:3538-41.
Conclusion
8. Hire R, Kale AS, Dakhale GN, Gaikwad
CES-D-R 10 scale was found to be very useful N. A Prospective, Observational Study of
instrument for screening of depression. Depression Adverse Reactions to Drug Regimen for Multi-
among MDR-TB is a common entity which should Drug Resistant Pulmonary Tuberculosis in
be taken care of on priority bases. Therefore it is Central India. Meditterr J Hematol Infect Dis.
recommended that during treatment all the patients 2014;6(1):e2014061.
should be screened for depression at least once and staff
of DOTS centre should be educated about symptoms of 9. Nair D, Velaytham B, Kannan T, Tripathy J
depression and the counselling techniques for improving P, Harries AD, Natrajan M, Swaminathan S.
patient compliance. Predictors of unfavourable treatment outcome in
patients with multi-drug resistant tuberculosis in
Source of Funding: Nil. India. Int Union Against Tuberculosis and Lung
Disease. PHA. 2017;7(1):32-8.
Conflict of Interest: None
10. Thiruvalluvan E1, Thomas B, Suresh C, Sellappan
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DOI Number: 10.5958/0976-5506.2019.01608.5

Incidence of Pulmonary and Extrapulmonary Tuberculosis

among Jaintia Tribes, Meghalaya: A Hospital based Study

Arpita Mitra1, Roumi Deb2

1
Research Scholar, 2HOD & Addl. Director, Amity Institute of Anthropology, Amity University, Sector-
125, Noida, Uttar Pradesh, India

ABSTRACT
Tuberculosis (TB) is a global public health problem. Pulmonary tuberculosis (PTB) is most common and
highly contagious infection, whereas, Extrapulmonary tuberculosis (EPTB) in also an important clinical
problem. The present study aimed to evaluate the demographic factors associated with PTB and EPTB
patients of Jaintia Hills, Meghalaya. Total 317 patients clinically diagnosed with TB and belonged to the
age group 15-50 years were enrolled for the study from different health centres of Jaintia Hills. Out of all
the TB patients, 64.4% had PTB and 35.6% were diagnosed with EPTB. Male were more frequently
affected by PTB (61.1%), whereas EPTB was more detected among female (57.1%) and found to be
statistically significant (p=0.002). Significant differences (p<0.05) were also observed between other
demographic parameters such as religion (p=0.000), community (p=0.008), marital status (p=0.000) and
occupation (p=0.000) with type of TB. Early detection and appropriate treatment of TB must be started as
soon as possible for reduction of this disease with increased awareness among the community.

Keywords: Tuberculosis, Pulmonary, Extrapulmonary, Jaintia Hills,

Meghalaya.
Introduction bones 1-2,7. Nearly all organs of the body can be infected
by EPTB and it can also have a wide variety of clinical
Tuberculosis is public health challenge in almost all
manifestations, thus leading to difficulty and delay in
developing countries and estimated that almost one-third
diagnosis8. Socio-demographic factors such as age, sex,
of the population is infected globally1-2. India is the
education, occupation, marital status, life style play a
highest TB burden country and accounting for one-fifth
crucial role in etiology and epidemiological situation of
global incidence of this disease 3. More prevalent age
TB9. Therefore, the present study was conducted
group of this infectious disease is 15-54 years. Lack of
focusing on demographic factors associated with
awareness and negligence towards symptoms and
pulmonary and extrapulmonary tuberculosis among the
treatment are the major cause of increasing the number
Tribes of Jaintia Hills, Meghalaya.
of TB patients. Fear of death and social stigma are the
other important reasons for hiding of truth regarding
the disease4. PTB is highly contagious infection. The Method
proportion of PTB and EPTB varies with respect to A cross-sectional study was conducted among 317
geographical exposure, social, ethnic and economical patients diagnosed with TB at the health centres of
parameters5-6. The most common sites for EPTB are Jaintia Hills (East and West), Meghalaya. Since, the
lymph nodes, pleura, cutaneous tissue, abdomen, present study was a part of ICMR funded project entitled
gastrointestinal system and “Prevalence and Risk Factors leading to HIV Infection
among the Two Tribes of Jaintia Hills, Meghalaya and
Correspondence Author: Ethical clearance for ICMR funded project was sought
Ms. Arpita Mitra from Amity University Research Ethics Committee.
Research Scholar Patients belonged to the age group 15-50 years were
Amity Institute of Anthropology, Amity enrolled for the study. Written permission was sought
University Sector-125, Noida, Uttar Pradesh- from District Medical and Health Officer (DM&HO)
20130, India Email:
[email protected]
434 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 434

and Medical officers (MOs) of all the health centres Table 1 shows the demographic distribution of TB
before conduct the study. Informed consent was patients with respect to type of TB. It was observed that,
obtained from each patient prior to conduct the interview among all the subjects 65.2% were male and 37.5%
and gathered information kept confidential. To collect were female. Amongst all male, majority (61.1%) were
the demographic data such as age, sex, religion, infected with PTB; whereas amongst female, 57.7%
community, occupation, marital status, structured were diagnosed with EPTB. Distribution of gender
schedule was used. Statistical analysis was carried out with type of TB was found to be highly significant
using SPSS V22. Differences between frequencies were (p=0.002). With respect to age group, patients between
tested using Chi- square test (significance level p<0.05). 31-40 years of age were more prone to PTB, whereas a
different finding was observed for EPTB cases.
However, these differences were not found to be
Results
statistically significant (p≥0.05). Most of the Christian
The study revealed that, of 317 TB patients (69.7%) and Niamtre (85.5%) group were found to be as
64.4% pulmonary tuberculosis patients. Different scenario was
were diagnosed with PTB and 35.6% had EPTB (Fig. observed for Hindu as majority of them were infected
1). with EPTB (59.8%). Statistical analysis shows a highly
significant variation between region and type of TB
(p=0.000). Majority of the TB patients belonged to
Jaintia community (85.5%), among them 66.6% had
PTB. Significant distribution was observed with respect
to community and type of TB (p=0.008). Married group
in Jaintia hills were majorly affected with PTB (71.2%)
as compare to unmarried group which was more prone
to EPTB (58.1%) and also found to be statistically
highly significant (p=0.000). occupation is an
important parameter responsible for exposure of
tuberculosis. Around, 40% of the patients were
involved with coal mine work, which shows a relevant
cause for high prevalence of TB infection in Jaintia hills.
Approximately, 86% PTB patients were coal mine work-
ers in the present study. Occupation is also found to sig-
Fig. 1: Distribution of Pulmonary and nificantly associated with type o tuberculosis (p=0.000).
Extrapulomonary Tuberculosis

Table 1: Demographic distribution of TB patients by type of TB:

PTB Patients EPTB Patients

Variables Total p value
N % N %
Gender
Male 121 61.1 77 38.9 198
0.002*
Female 51 42.9 68 57.1 119
Age group (in year)
<21 11 57.9 8 42.1 19
21-30 48 58.5 34 41.5 82
0.143
31-40 123 69.9 53 30.1 176
40+ 22 55.0 18 45.0 40
Religion
Christian 101 69.7 44 30.3 145
Hindu 39 40.2 58 59.8 97 0.000*
Niamtre 64 85.3 11 14.7 75
Conted…

Community
Jaintia 184 67.6 88 32.4 272
Garo 1 25.0 3 75.0 4 0.008*
Khasi 19 46.3 22 53.7 41
Marital Status
Married 173 71.2 70 28.8 243
0.000*
Unmarried 31 41.9 43 58.1 74
Occupation
Coal mine workers 109 85.8 18 14.2 127
Driver 65 58.6 46 41.4 111
Vendor 11 61.1 7 38.9 18
Store keeper 7 41.2 10 58.8 17
0.000*
Sex worker 2 40.0 3 60.0 5
Health workers 2 28.6 5 71.4 7
Private employee 5 23.8 16 76.2 21
Unemployed 3 27.3 8 72.7 11
Total 204 64.4 113 35.6 317
Discussion Several social determinants and risk factors are
impediments to TB control in high burden countries
The incidence of TB is one of the most important
such as: poverty, malnutrition, HIV, smoking, diabetes
surveillance indicators in public health. The present
mellitus, alcoholism, indoor air pollution, presence
study revealed that the pulmonary tuberculosis was
higher among male (61.1%) as compared to females, of large numbers of undiagnosed or poorly treated
whereas, female (57.1%) were more prone to infectious pulmonary TB diseased persons in the
extrapulmonary tuberculosis than male, which showed community, overcrowding and weak health systems19.
highly significant differences (p=0.002). These However, TB control efforts are primarily based on early
differences could be due to regional, cultural and diagnosis and treatment of patients with pulmonary TB
occupational variations. Similar findings were observed disease. Chronic, productive cough is one of the cardinal
in urban area of Pune, Maharashtra, Nepal and West symptoms of pulmonary TB disease, and therefore it is
Africa9-11. However, no statistical significance was recommended that all individuals who have a productive
observed with respect to age and type of TB, but it was cough of two weeks or more in high burden countries be
found that more than half of the TB patients (55.5%) evaluated for TB20-21.
belonged to the age group 31-40 years. According to
WHO (2018), tuberculosis mostly affects adults in their Conclusion
most productive years; however, all age groups are at
The present study concludes that the proportion
risk. Around 95% of cases and deaths have been
occurred in developing countries12. Variables like of pulmonary tuberculosis was significantly higher
religion (p=0.000), community (p=0.008), marital status among male than their counter part. Female constituted
(p=0.000) had highly significant association with PTB with majority of the patients with extrapulmonary
and EPTB in accordance with other study9. The present tuberculosis. Other demographic factors such as region,
study confirmed that nearly 40% patients were working community, marital status, occupation were significantly
in coal mine areas. Occupation is an important risk associated with tuberculosis in Jaintia hills, Meghalaya.
factor responsible for active PTB in general Early detection and treatment of TB along with creating
population13. Findings of the other studies confirmed awareness regarding preventive measures for TB
that patients were exposed to coalmine dust were more patients in various infection prevention programme is
prone to tuberculosis, which was a known cause of necessary in Jaintia Hills. It is also very important to
occupational risk factors for tuberculosis14-18. make sure the
availability of anti-tuberculosis regimens in all Health 6. Global Tuberculosis Control. WHO Report.
Centres of Jaintia Hills. Tuberculosis control programs Geneva: World Health Organization; 2002.
must be targeted at specific populations under risk with Surveillance, Planning, Financing.
special care on young and female populations to reduce
7. Musellim B, Erturan S, Sonmez Duman E and
TB morbidity and mortality.
Ongen G. Comparison of extra-pulmonary and
pulmonary tuberculosis cases: factors influencing
Acknowledgement the site of reactivation. Int J Tuberc Lung Dis.
Sincere thanks to ICMR for financial support. 2005; 9: 1220–1223.
We are thankful, to Heads of the Jaintia Hills District 8. Gonzalez OY, Adams G, Teeter, LD, Bui TT,
Administrative and Health Centers for their support. Musser JM and Graviss EA. Extra-pulmonary
Heartfelt thanks to the participants of Jaintia Hills for manifestations in a large metropolitan area with a
their cooperation in providing the valuable information. low incidence of tuberculosis. Int. J Tuberc Lung
Dis. 2003; 7: 1178-1185.
Conflict of Interest: NA.
9. Bhawalkar J, Khedkar D, Lanjewar B, Landge
Ethical Clearance: The present study was a part of J and Ghonge S. Socio-Demographic Factors
Indian Council of Medical Research (ICMR) funded Associated with Tuberculosis Cases Registered
project, so, the Ethical clearance was sought for the Under RNTCP in an Urban Area of Pune,
project from Amity University Research Ethics Maharashtra. National Journal of Community
Committee. Medicine. 2018; 9: 130-134.
10. Mohammed T, Sharma S, Roherberg D, Gupta
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DOI Number: 10.5958/0976-5506.2019.01609.7

An Automatic Disease Early Prediction and Diagnosis

Recommendation Framework for Brain Tumours

Nandan Bodapalli1, Kunjam Nageswara Rao2, Parada Vara Prasad Dora3

Research Scholar, 2Professor, Department of CS & SE, AUCE(A) at Andhra University,
1

Visakhapatnam, AP; 3MBBS, MD Cardioanesthesia at Omni RK Hospital, Seven Hill Road,

Visakhapatnam, AP, India

ABSTRACT
Use of computation techniques in medical research have progressed to a greater extend with the availability
of higher order complex and accurate algorithms for detecting diseases. The medical diagnosis processes
with human intervention cannot match with the demands from the consumers as the human process is slow
and less accuracy as it completely depends on the skills of the individuals. One of the prominent medical
diagnosis is detection of brain tumours cells. Human brain being the most important component of the
body, can cause multiple other life-threatening diseases. These diseases are caused due to the presence
of tumour in the brain cell. Hence, this research attempts to propose a higher accurate tumour detection
algorithm. The improved accuracy is achieved due to the novel proposed dynamic intensity-based MR
image enhancement algorithm and the proposed adaptive coefficient-based segmentation algorithm.
Further, it is also been observed that, the presence of the tumour in the brain cortexes can lead to other
diseases as well. These diseases from a large number of possibility space, can take a huge amount of time to
diagnose and further propose medications. Hence a reduction of the possibility space and the reduced
diagnosis process can give more time for medication to save the precious human life. Thus, yet another
objective of this research is to automate the disease early prediction by recommending the diagnosis for
reduced number of diseases by applying tumour centroid detection and mapping to human brain cortex
functionalities. The work demonstrates a very high 97% accuracy for the detection and early prediction.

Keywords: Tumour Detection, MR Image Enhancement, Adaptive segmentation, Tumour Region

Detection, Disease Early Prediction, Diagnosis Recommendation.

Introduction The primary source of information processing to

detect the brain tumours are the MR images captured
In last few decades, reports from various medical
statistics analysis organizations have demonstrated that during the initial diagnosis. Various research attempts
there is a significant increase in the brain tumour have reciprocated the advantages of using MR images
effected patients from various parts of the world. The for such diagnosis. One of the most recent work by
most recent study by A. S. Mohammad et al.1 have R. M. Chen et al.5 have proven the similar believes by
shown that the nearly over 50,000 reports only in the showcasing higher accuracy compared with the MR
year of 2017 in different states of USA. These reports images with other mediums. Though the MR Imagining
and datasets have intrigued the demand for further technique is criticised by some group of researchers due
research and early prediction of brain tumours in the to the presence of noise and additional time complexity
human brain. D. E. Job et al.2 have reported a processed
for removing and enhancing the image during the pre-
dataset with nearly
processing phases, the work by C. C. Benson et al. 6 and
90,000 patient information captured in the form of MR
imagining for further analysis. This dataset is a major the work by A. Jenitta et al.7 have demonstrated two
collection or the major set of BRATs datasets. Similar newer advantages as possibilities of fractal analysis and
studies have also demonstrated that, due to the complex easy image data retrieval on MR images respectively.
symptoms, the detection of the brain tumour and the Thus, this research proposes a novel automated
cancerous growth is highly delayed. Hence, the demand framework for Disease Early Prediction and Diagnosis
for early detection of brain tumours and diseases might Recommendation for Brain Tumours.
be caused by the tumours cannot be ignored.
439 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 439

Literature Review Brain Function Processing Analysis: In this section of

the work, the working paradigm of the human brain is
Analysing and detecting the brain anomalies highly
analysed for having better understanding of the tumour
relies on tumours and other factors causing the tumours
detection and subsequently the disease detection.
such as injuries to the brain cortex, both external and
internal, damages to the brain cell tissues due to multiple The human brain cortexes are majorly divided
effects. The wide variety of the possibilities for tumour into six compartments to contain Prefrontal Cortex,
formation makes the task to identify the classes of the Amygdala, Neocortex, Hippocampus, Cerebellum and
tumours. The work by P. M. Shakeel et al.7 is the most Basal Ganglia.
recent analytical study to identify the connectivity
Prefrontal Cortex: Prefrontal cortex region has been
of these parameters to realise the tumour detection.
implicated in planning complex cognitive behaviour,
The capturing or extraction of these interdependent
personality expression, decision making and social
parameters is made possible with the improvements in
behaviour. It is considered to be orchestration of
the medical imaging techniques such as CT scan or the
thoughts and actions in accordance with internal goals.
MRI scans. Though, the extraction of the parameters still
a highly complex process until the work presented by S. Amygdala: It is part of the limbic system of the brain,
Baskar et al.8 with the improvisation of error reduction which involved with emotions and other reactions to
in the brain imaging data. This work is further tested stimuli. It is highly involved with different emotional
and compared by L. Keinan-Boker et al.9 with other responses.
parallel research works. The conclusion made by various
Neocortex: It is part of cerebral cortex. It is involved in
researchers that the recent methods for error reduction
functions like sensory perception, generation of motor
is highly complex and cannot justify device related
commands, conscious thoughts and spatial reasoning.
influences during the noise reduction and MR image
enhancements. Thus, a demand for higher accurate Hippocampus: It is a small organ located within the
and higher adaptive model is expected by the research brain medial temporal lobe and it is part of limbic
community to improve the complete tumour detection system, the region that regulates emotion. It is
process. This work addresses this issue and proposes a associated with long-term memory.
novel image enhancement model.
Cerebellum: It receives information from the sensory
Further, for classification of the brain tumours, a systems, the spinal cord and other parts of the brain and
wide range of the methods were introduced by various regulate the motor movements such as posture, balance,
research attempts. The most recent outcome reported coordination and speech.
by K. Usman et al.10 is to install machine learning
Basal Ganglia: It is part of Cerebrum strongly
components in the detection framework for tumour interconnected with cerebral cortex, thalamus and brain
detection. The machine learning algorithms are expected stem other brain areas. It includes the functionality like
to perform highly accurate detection and classifications habit learning, eye movement, procedural learning, and
for the tumour detection. Provided, the algorithms are cognition and emotion.
feed with enough training data. The problem arises in
case of tumour detection as in case of every subject or Brain Disorder Diseases: In order to map the diseases
patient, the tumour formation is different and lease very based on the tumour location, it is important to
less similarity-based detection possibilities, which lead understand the complications and effects from the
to higher time complexity for each training phase and diseases. Hence, in this section of the work, the diseases
results into higher time complexity. This phenomenon are discussed and finally mapped with the location of
was established by L. Lefkovits et al.11 tumours.

Henceforth, with the understanding of the parallel Motor Memories Dysfunction: It is contextual
interference effect resulting loss of short-term and long-
research outcomes and the limitations, this work
term motor memory.
obtains a direction to model the new algorithms for the
automated framework. Parkinson’s Disease: Nerves in a central area
of
the brain degenerate slowly, causing problems with
movement and coordination. Early signs are a tremor of Methodology and Proposed Framework
the hands, stiffness of the limbs and trunk, slowness of
movement and unstable posture. Firstly, the images captured from the MR imaging
devices must be pre-processed, normalized by
Huntington’s Disease: An Inherited nerve disorder that removing noise and blurriness and then is applied to
causes a degeneration of brain cells. Dementia, a decline DIBIE Algorithm to get enhanced images and apply
in cognitive function due to malfunction of nerve cells in to AICISA Algorithm for segmentation and identify
the brain, mood swings, depressions and irritability are the tumours regions and locations can be identified by
its symptoms. TCDCF Algorithm and Finally mapping with Brain
cortex with KVBDP Algorithm with useful for Disease
Alzheimer’s Disease: It is most common form of
Recommendation for doctors. The followings algorithms
dementia, causing progressive loss of memory and metal
are described as Tumour Based Disease Prediction
functions and changes in behaviour and personality.
Framework as shown in [Fig. 1]

Fig. 1: Tumour Based Disease Prediction Framework

Algorithm 1: Dynamic Intensity Based Image Enhancement Algorithm (DIBIE)

Step - 1. Accept the MR Image
Step - 2. For each pixel in the image
a. Calculate the gray intensity as GI[i][j]
b. If GI[i][j] > GI[i+1][j+1]
c. Then
i. MaxGI[k(i),k(j)] = GI[i][j]
ii. Cord[k(i),k(j)] = i,j
d. Else
i. MaxGI[k(i),k(j)] = GI[i+1][j+1]
ii. Cord[k(i),k(j)] = i+1,j+1
Step - 3. End
Step - 4. For each Maximum Intensity Point
a. Increase the intensity difference as
b. MaxGI[Cord[k(i),k(j)] = {MaxGI[Cord[k(i),k(j)]] - MaxGI[Cord[k(i+1),k(j+1)]])}.
log(MaxGI[Cord[k(i),k(j)]] + MaxGI[Cord[k(i+1),k(j+1)]]))}
c. If MaxGI[Cord[k(i),k(j)]]{t}> MaxGI[Cord[k(i),k(j)]] {t+1}
d. Repeat Step - 2
Step - 5. End
The Algorithm-1 describes about the dynamic
Algorithm 4: Key Value Map Based Disease
intensity based Image enhancement for remove noise in
Prediction Algorithm (KVBDP)
the image and blurriness and identifies the coordinates of
Step1. Build the Key-Value Pair Set for Disease
maximum gray intensity level.
set,D
The Algorithm-2 describes about the adaptive a. As <<CS[i],D[j]>>
intensity coefficient based image segmentation to b. Accept the Composite Centroid Set,
tumour regions. CC[K]
Step - 1. For each CC[K]
Algorithm 2: Adaptive Intensity Coefficients Image a. Identify the cortex from Cortex Set, CS
Segmentation Algorithm (AICISA) b. If CC[K] belongs to CS[i]
Step - 1. Accept the enhanced MR Image c. Then
Step - 2. Calculate the mean intensity i. Mark CS[i] as tumour affected Cortex
Step - 3. Calculate the intensity variance ii. Return D[j] for {CS[i],D[j]}
Step - 4. Calculate the adaptive intensity Step - 2. End
coefficient as MaxMember = {Mean,Variance}
Step - 5. For each pixel The results obtained from the proposed algorithm
a. Identify the pixels for maximum and the framework is furnished for Patient 1,2,3 &4 for
likelihood tumour location and Centroid detection [Fig. 2].
b. Build classifier for each pixel likelihood
i. For each class
1. Mark the region
Step - 6. End
Step - 7. For each marked region
a. Check for brain cell area and cell volume
i. If region_cell_volume = brain_
cell_area % 10
Patient-1 Patient-2
ii. Then
1. Mark the region as
Tumour
Step - 8. End

The Algorithm-3 describes about the tumour

centroid detection using curve fitting method.
Algorithm 3: Tumour Centroid Detection using
Curve Fitting Algorithm (TCDCF)
Step - 1. Accept the Tumour regions Patient-3 Patient-4
Step - 2. For each region Fig. 2: Patient – 1, 2, 3, 4 Tumour Location and
Centroid Regions
a. Apply curve fitting method to match the
regular geometric shapes Results and Discussion
b. Calculate the centroid for each shape as
C[i] The results obtained from the proposed framework
c. Calculate the composite centroids as and the novel algorithms are highly satisfactory and are
CC[K] from C[i] furnished here.
Step - 3. End Firstly, the tumour region size detection results are
furnished with brain cell tumour volume and tumour
The Algorithm-4 describes about the Key Value
volume. This work usages the BRATs 2010 dataset,
Map based disease prediction based on Centroid set.
which includes 500 patient data. Nevertheless, the work
demonstrates the results with 50 patient data.
The proposed framework demonstrates high Finally, Tumour & Brain Cortex Mapping [Fig.
accuracy. The extracted results are analysed, the 4] and the disease diagnosis recommendation results
diameter of the detected tumour region and the tumour are furnished in [Table-1]. Finally, the 97% accuracy
volume to brain cell volume ratio is analysed analysis is obtained from 100 datasets of tumour data, 97
graphically [Fig. are correctly identified and 3 incorrectly identified form
3]. The table also shows the result regions detection the proposed framework [Table-2].
based on the threshold of the ratio and the diameter and
centroids for the tumour cells are anlysised.

Fig. 4: Tumour & Brain Cortex Mapping

Fig. 3: Tumour Region Extraction Results

Table 1: Disease Recommendation

Disease Early Prediction and Diagnosis
Test Run Brain Cortex
Recommendation
1 Hippocampus Episodic Memories recall Dysfunction
Motor memories dysfunction
2 Prefrontal Cortex Short-term memory loss
working memory dysfunction
Sensory Disperception Irregular
Motor Commands Spatial
3 Neocortex
Reasoning Problem Language
Interpretation Problem
Fine Motor Control Errors
4 Cerebellum
Vestibulo-Ocular Reflex Error
5 Hippocampus Episodic Memories recall Dysfunction
Emotional dysfunction
6 Amygdala
post-traumatic stress disorder
7 Undetected Undetected

Table 2: Accuracy Analysis

Number of Datasets Tumour Data Correctly Identified Incorrectly Identified Accuracy
100 100 97 3 97%
Conclusion possibility space of the medical treatments. Further, the
detection of the tumour by accurate location is
This work proposes a novel automated framework
significant. Hence, this work deploys another novel
for detection of brain tumour with higher accuracy and
curve fitting based algorithm to detect the tumour
early recommendation of diagnosis for reducing the
centroid and the radius to map the tumour region to
the brain cortexes.
After the successful mapping of the brain tumour to 6. A. Jenitta, R. S. Ravindran et.al. Image retrieval
the brain cortex, this work further deploys another based on local mesh vector co-occurrence pattern
key-value map novel algorithm for possible disease for medical diagnosis from MRI brain images:J.
mapping. This mapping process significantly reduces Med. Syst. 2017 Aug 31;41(10):157.doi:10.1007/
the time to diagnosis and start the medication process s10916-017-0799-z.
on the subject. The proposed framework, as explained,
7. P. M. Shakeel, S. Baskar, V. S. Dhulipala, S.
demonstrates a higher accuracy of 97% in detection and
Mishra, M. M. Jaber, et al. Maintaining security
early prediction of tumour and tumour-based diseases to
and privacy in health care system using learning
make this work be considered as one of the benchmark
based deep-Q-networks:J. Med. Syst.. 2018;
contributions to this field of study.
42(10): 186.
Ethical Clearance: Taken from Dr. Parada Vara Prasad 8. S. Baskar, V. R. Dhulipala, et al. Biomedical
Dora, MBBS, MD, Cardioanesthesia, Omni RK rehabilitation: Data error detection and correction
Hospital, Vishakapatnam. using two dimensional linear feedback shift
Source of Funding: Self register based cyclic redundancy check: J. Med.
Imag. Health Informat. 2018; 8(4): 805-808.
Conflict of Interest: Nil
9. L. Keinan-Boker, E. Friedman, B. G. Silverman
et al. Trends in the incidence of primary brain
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in an experimental model of brain metastases of classification from multi-modality MRI using
triple negative breast cancer: Pharm Res. 2018 wavelets and machine learning: Pattern Anal.
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DOI Number: 10.5958/0976-5506.2019.01610.3

Does Right Hand Second Digit to Fourth Digit Ratio Correlate

with Primary Infertility in Males?

Narendran Krishnamoorthi1, Nikhil Shetty2, Nandita Shenoy3, Ashok Shenoy4, Christopher C Pais5,
Muralidhara Yadiyal6
1
Post Graduate, Department of General Medicine, 2Associate Professor, Department of OBG, Kasturba
Medical College, Mangalore. Affiliated to Manipal Academy of Higher Education, Manipal; 3Department
of Oral Medicine and Radiology, Manipal College of Dental Sciences, Mangalore. Affiliated to Manipal
Academy of Higher Education, Manipal; 4Department of Pharmacology, 5Professor, Department of
General Medicine, 6Department of General Medicine, Kasturba Medical College, Mangalore. Affiliated to
Manipal Academy of Higher Education, Manipal

ABSTRACT
Introduction: Male infertility is one of the areas of prime interest nowadays. There are various causes for
Male infertility. Identifying the correct cause and appropriate treatment can improve fertility rate. One such
approach is the association of digit ratio (2D:4D) with fertility. In this regard there is paucity of literature
in Indian setup. The aim of this study was to correlate the association between digit ratio and Sperm count
with testosterone levels.
Materials and Method: In this Case-control study, 79 primary Infertile males with oligozoospermia
and
79 age matched controls were selected and their right hand 2nd and 4th digits were measured using Vernier
caliper. 2D:4D values are calculated and correlated with sperm count and testosterone levels. Statistical
analysis was done to find the significance.
Results: Male Infertility peaks at the age group of 31-40 years. The 2D:4D values are increased in infertile
males and it increases with decreasing sperm count and decreasing Testosterone levels and they were found
to be statistically significant and shows negative correlation.
Conclusion: The 2D:4D values negatively correlates with sperm count and testosterone levels. This implies
that digit ratio can serve as an indicator of testosterone level and sperm count thereby male fertilit y. It is a
promising diagnostic or predictive marker of male infertility.

Keywords: 2d:4d, Male infertility, Hox genes, Sperm count

Introduction a relatively uncommon cause of infertility. But now
abnormalities in male are identified as independent
Infertility is a term applied for couple’s who are
cause of Infertility in about 60-80 million couples
unable to get pregnancy after a year of unprotected
who suffer from infertility and it is recognized as an
intercourse. In the past female partner was the primary
important contributory factor in 20-30% couples with
focus of attention and male factors were regarded
reproductive failure.1 Majority of Male infertility is
as
due to reduced sperm count and accurate diagnosis and
prompt treatment can reverse male infertility and thus
Corresponding Author: Dr can avoid costly artificial insemination procedures. The
Muralidhara Yadiyal Department development of a person’s fingers and toes begins at the
of General Medicine, age of 6th week of gestation.2 Digit ratios are determined
Kasturba Medical College, Mangalore during embryonic development and will then remain the
Affiliated to Manipal Academy of Higher Education, same without change after birth. So, any alterations in
Manipal the intrauterine environment at this embryonic
Email: [email protected] period
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 445

such as intrauterine under nutrition or changes in the office excel worksheet and analyzed using statistical
hormonal levels, in addition to changes in fetal organ software SPSS version 17.0. Descriptive statistics like
structures, the development of fingers and toes of the mean, proportion and standard deviation were used for
fetus also will be affected. There is a family of genes expressing the Results. For categorical values chi square
called Hox genes which regulate the development of
test used and for quantitative data student unpaired ‘t’
both the genital system and limb development. Hence
test used and p value < 0.05 was considered statistically
change in the digit ratio (2D:4D) can reveal defects in
significant. Confidence interval is 95% and Power of
Hox gene and indirectly indicate defect in genital
system. Based on this concept, we aim to look into the study is 80%.
possibility whether
2D:4D digit ratio and fertility can serve as a diagnostic Results
and prognostic tool in male infertility among the South
Our study subjects and controls were under the
Indian population.
age group of 31-40years. The measurement error was
ruled out by calculating repeatability values which
Materials and Method
showed nil significant values with anova calculations.
This study is case control study conducted in Mean length of second digit was 68.583(SD- 5.758,
Kasturba Medical college and hospitals, Mangalore CI- 67.294 to 69.873) in cases and 67.172(SD- 6.745,
and Govt. Wenlock hospital, Mangalore. All outpatient CI- 65.661 to 68.683) in controls with t value 1.414
cases of primary infertility aged between 21-50 years, and p value of 0.159. Mean length of fourth digit
who satisfied the inclusion and exclusion criteria were was
recruited for the above study as subjects and equal 68.622(SD- 6.018, CI- 67.274 to 69.970) in cases
number of controls were selected. Patients with sperm and
analysis below the reference value and with normal or 69.603(SD- 7.405, CI- 67.944 to 71.261) in controls
increased FSH and LH were taken as Cases and age with t value 0.914 and p value of 0.362. The ratio of
group matched Males found to have normal sperm length of second and fourth digit was calculated and
count (fertile) during infertility work up were taken as the mean value among cases was 1.000 with 95%
Controls. Confidence Interval(CI) 0.996-1.003. The mean value
among controls was 0.996 with 95% CI 0.956-0.975. It
Patients with age > 50 yrs and age <21yrs, those
was observed that the mean value of 2D:4D was higher
with visible gross deformity of hand and fingers,
in infertility cases than in controls and it was statistically
testicular atrophy due to infections, injuries to urogenital
found to be highly significant with t test p value <0.001.
system, varicocele, patients on drugs like Chlorambucil,
(Table-1). Azoospermic men also showed higher 2D:4D
Cyclophosphamide), Anabolic Steroids, Spirinolactone,
value with 1.009 compared to oligozoospermic men
Flutamide, Ketoconazole, Gnrh analogs, history of
where the 2D:4D value was 0.998. The 2D:4D value in
substance abuse, excessive alcohol consumption and
men with normal count was still lower with 0.966. This
smoking (those who smoke>10 cigarettes/day) were
association was found to be statistically significant with
excluded.
p value of 0.024. The mean value of level of testosterone
After taking Informed consent, Information was was calculated as 2.915 (with a SD-1.223, 95% CI
collected from cases with reduced sperm counts and of
Hospital based controls, and the comparison made 2.641-3.189) among cases and 7.953 (with SD
between their finger length ratio pattern. Right hand 2nd -2.737,
digit and 4th digit was directly measured with Vernier 95% CI of 7.34-8.566) among controls. This shows
caliper on the ventral surface of the hand from the basal that the level of testosterone is significantly low among
crease of the finger to the distal tip. When there was infertility cases compared to normal controls with a p
thick crease at the base of digit, measurement started value of <0.001. On correlating the 2D:4D values with
from the most proximal crease. Data were entered in level of testosterone among the whole sample, it was
Microsoft found that the value of 2D:4D correlated well with the
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 446
level of testosterone with significant p value of 0.000
and Pearson correlation of -0.446. (Fig 1).
446 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Table 1: Mean values of 2D:4D in right hand of infertility cases and controls
95% CI of Mean
N Mean SD t value p value
Lower Bound Upper Bound
Cases 79 1.000 .016 .996 1.003 7.418 .000
Controls 79 .966 .037 .958 .975 <0.001, HS
Total 158 .983 .033 .978 .988

Fig 1: Correlation of 2D:4D values with testosterone levels

Discussion prenatal testosterone has some influence in fixing digit
ratio.8,9,10 So any insult during this period like hormonal
World Health Organization defines “Infertility changes, undernutrition influence digit ratio in addition
is a disease of the reproductive system defined by the to affecting internal organs and digit ratio can also
failure to achieve a clinical pregnancy after 12 months indicate intrauterine environmental changes. Manning
or more of regular unprotected sexual intercourse 3. 60- et al compared digit ratio of second and fourth digit in
80 million people worldwide are suffering from right hand with fertility and found out that low 2D:4D
infertility out of which male infertility constitutes 20- ratio was associated with higher testosterone level and
30% cases. Urogenital and limb development are high sperm count. They also proposed that right hand
controlled by Homeobox family of genes, the vertebrates is more sensitive which is explained by the laterality
Hox genes are required for the growth and patterning of in the association of dermatoglyphic asymmetry and
digits and differentiation of genital bud. Homeobox testosterone.11,12 Wood et al found that lower 2D:4D
gene sperm is transiently expressed prior to meiosis in ratio is correlated significantly with high sperm count
germ cells, whereas Hoxa4 is expressed specifically in and higher levels of testosterone.13 Lu hong et al14 done
post meiotic germ cells. Hoxb4 is expressed both in a study on 2d:4d, 2d:3d, 3d:5d, 4d:5d, 2d:5d ratios
somatic cells and germ cells of testis. Hox1a expressed with relation with infertility and found that 2d:4d
by leydig cells4. The dual control of Hox gene over ratio compared to other ratios has more relationship
limbs and urogenital development and the fact that with hormonal patterns.(Table 2). By supporting these
Digit ratio can indirectly indicate the status of Hox studies, our study results showed that 2D:4D values are
gene thereby the genital development and fertility significantly high in infertile men compared to normal
were explained by theories proposed by Denis Duboule males, 2D:4D v alue decreases with increasing sperm
and Herfautte and Piechel5,6. Hence modulators of count with statistically significant p value, Testosterone
Homeobox gene expression and function like positive levels are significantly low in infertile men compared
modulators in case of male infertility and negative to normal males, Testosterone level increases with
modulators in male birth control can serve as future increasing sperm count with significant p value. 2D:4D
therapeutic goals7. Also the peak production of value negatively correlates with testosterone level with p
testosterone and fixation of digit ratio occurs at same value <0.001and with Pearson correlation -0.446.
period of intrauterine life and
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 447

Table 2: Comparison of 2D:4D values in various studies

2D:4D H.Lu et al49 Manning et al57 Current study
Infertile cases 0.949 1.00 1.00
Normal controls 0.9478 0.97 0.966
Conclusion 5. N.Lonfat, T.Montowon, D.Duboule.
Convergent evolution of complex regulatory
Male infertility is a growing problem, identifying
landscapes and pleiotrophy at Hox loci.
the correct cause and appropriate treatment can improve
Science, 2014;346(6212):1004 DOI :10.1126/
fertility rate. One such approach is the association of
science.1257493
digit ratio (2D:4D) with fertility. This study showed
an inverse association between digit ratio, testosterone 6. Herault Y, Fradeau N, Zakany JU. A regulatory
level and sperm count. The study showed that digit mutation inducing both loss-of function of posterior
ratio can serve as an indicator of testosterone level Hoxd genes. Development 1997;124(18):3493–500.
and sperm count thereby correlate with primary male
fertility. We conclude that digit ratio (2D:4D) can be 7. Mortlock, D.P. and Innis,1997, Mutation of
used as a diagnostic or predictive marker of primary Hoxa13 in Hand Foot Genital syndrome, Nat.
male infertility and that Hox gene modulators can serve Genet.15:179.
as useful future therapeutic modulators, which can avoid 8. Malas MA, Dogan S, Hilal Evcil E, Desdicioglu
costly artificial insemination procedures. K. Fetal development of the hand, digits and digit
Ethical Clearance: Taken from the institutional ethics ratio (2D:4D). Early Hum Dev 2006; 82:469–75.
Committee, Kasturba Medical College, Mangalore. 9. BerenbaumSA, Bryk KK, NowakN, Quigley CA,
Moffat S. Fingers as a marker of prenatal
Source of Funding: Self.
androgen exposure. Endocrinology 2009;
Conflict of Interest: Nil 150:5119–24.
10. Hurd PL, Vaillancourt KL, Dinsdale NL.
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second interagency meeting, 2001. Geneva: digit length in azoospermic males undergoing
World Health Organization; 2001. p. 23. surgical sperm retrieval: predictive value for
sperm retrieval and on subsequent fertilization
4. Simon Wood, Ellen Vang, John Manning, Julie
and pregnancy rates in IVF/ICSI cycles. J
Walton, Steven Troup, Charles Kingsland, And
Androl
Iwan David Lewis-Jones. The Ratio of Second
to Fourth Digit Length in Azoospermic Males 2003;24(6):871–7.
Undergoing Surgical Sperm Retrieval: Predictive 14. Lu Hong, Huo Zheng-hao, Liu Yong-jie, Shi Zhi-
Value for Sperm Retrieval and on Subsequent yun, Zhao Jun-li, Correlations between digit ratio
Fertilization and Pregnancy Rates in IVF/ICSI and infertility in Chinese men., Early Human
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2003.
DOI Number: 10.5958/0976-5506.2019.01611.5

Prevalence and Characterization of Opportunistic Candidal

Infection among Patients with Type II Diabetes Mellitus

Sandhya Rani T.1, R. Srikumar2, E. Prabhakar Reddy3, S. Latha4

1
Research Scholar, Department of Microbiology, 2Research Associate, Centre for Research, 3Professor of
Biochemistry, 4Associate Professor, Department of Physiology, Sri Lakshmi Narayana Institute of
Medical Sciences, Affiliated to Bharath Institute of Higher Education, Pondicherry, India

ABSTRACT
Background and Purpose: Diabetic patients are more susceptible to oral candidiasis infection due to poor
glycemic control and therapeutic dentures and Xerostomia, which reduces the salivary flow and a salivary
pH disorder. In the current study, we aimedfor Prevalence and characterization of opportunistic Candidal
infection among patients with Type II diabetes mellitus.
Materials and Method: Oral washwere taken from the mouth of 400 participants and were cultured on
Sabourauddextrose agar (SDA) medium. The study was performed during January to December 2016 in
diabetic patients (n=400) admitted in medicine ward. The Candida spp. were differentiated by culture on
CHROMagar, Sugar assimilation test, Sugar fermentation test and antifungal susceptibility test.
Results: The frequency of Candida spp. was higher in diabetic patients. Oral candidiasis more significant
in females 129(52%), alcoholic 98(85%), smoker 89(77%) and Denture 174(71%). C. albicans was the
most prevalent species in diabetics 135(55%) followed by C. tropicalis 43(17.6%), C. dubliniensis 27(11%)
parapsilosis 15(6.1%), C. glabrata 15(6.1%) and C. krusei 9(3.6%). All C. albicanswere susceptible to
fluconazole. Non-albicans Candida isolates were shown to have higher azoleamphotericin B, ketoconazole,
itraconazolethan C. albicansisolates.
Conclusion: Our study clearly showed that diabetes patients are more likely to develop the Candida
infection.The scores were slightly higher among the females as compared to males. Furthermore, smoking
and denture were are at high risk of being infected.C. albicans was the most prominent species followed
by C.tropicalis. The knowledge of prevalence species distribution, rapid species identification, antifungal
susceptibility testing and the development of newer antifungal drugs are mandatory to achieve a decrease in
Candida infections

Keywords: Diabetes mellitus; Oral candidiasis; Fluconazole; Xerostomia

Introduction threats to health care in the 21st century. It is
estimated
Diabetes mellitus (DM) is a clinical syndrome, that there will be 380 million persons with DM in
which associated with deficiency of insulin secretion or 2025.1
action. It is considered as one of the largest DM reduced the T cells, neutrophil function and
emerging disorders of humoral immunity. Consequently, DM
increases the susceptibility to opportunistic fungal
infection such as predisposition to the manifestations of
Corresponding Author:
oral diseases like Candidiasis, which is associated with
Sandhya Rani T
poor glycemic control and therapeutic dentures.2 Oral
Research Scholar, Department of Microbiology, candidiasis is one of the superficial fungal opportunistic
Sri Lakshmi Narayana Institute of Medical Sciences,
infection and it mainly caused by Candida albicans.
Pondicherry, India-605502
Phone: 9581243317 Candida is a genus of opportunistic yeasts,
Email: [email protected] unicellular fungi that can cause oral, vaginal, lung and
sometimes systemic infections. Typical colonization
449 Indian Journal of Public Health Research
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Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 449

sites in the oral cavity include the mucosal surfaces Identification of Candida Species: CHROM Agar was
of the cheek and palate, which are sparsely populated prepared as per the manufacturer’s instructions. These
although certain specialized surfaces such as the plates were incubated at 30°C for 24-48 hours. Species
keratinized stratified squamous epithelium of the were identified on CHROM Agar by the morphology
palate. It can influence the microbial distribution of the and colour of the colony. The appearances of various
oral cavity as well as the surface of the tongue which Candida species on CHROM Agar were light green-
consists of saliva-coated desquamated epithelium for Candida albicans, cream to white- Candida glabrata,
microbial adhesion3and higher microbial density. The purple fuzzy- Candida krusei and blue to purple -
average concentration of oral yeasts in saliva has been Candida tropicalis. Germ tube test, pick a small portion
reported to be about 300–500 cells/ml. Usually Candida of an isolated colony was suspended in a test tube
species are present in the oral cavity of almost half of containing 0.5 ml of human serum then incubated
the population without causing disease. Asymptomatic at
carriage may cause a higher risk of Candida associated 37ºC for 2 hours then examined microscopically after 2
complications through yeast infections if they become hours for the presence of germ tube.
Immunodeficiency and immunosuppressed.4Oral
colonization of Candida is more prevalent in people with Chlymadosporeformation on corn meal agar
diabetes mellitusand many studies have shown a higher (Dalmau plate): Prepare Cornmeal agar in a 90mm
prevalence of Candida colonization in the oral cavity of plate. Divide the plate into 4 quadrants and label each
diabetics compared with non-diabetic individuals. quadrant. Using a sterile needle, lightly touch the yeast
colony and then make 2-3 streaks of approximately
The manifestation of oral Candidiasis can occur in 3.5 - 4cm long and
median rhomboid glossitis, atrophic glossitis, denture 1.2 cm apart. Place a flame sterilized and cooled 22mm
stomatitis, and angular chelitis. Oral candidiasis is square cover glass over the control part of the streak.
associated with a high density of yeasts in the lesions This will provide partially anaerobic environment at
which have been reported in 9% to 65% of the the margins of the cover slip. Incubate the plates at 25C
population.5 for 3-5 days. Remove the lid of the petriplate and place
In addition to C. albicans, Non albicansspp has been the plate in the microscope stage and focus the edge of
commonly isolated from diabetic patients are Candida the cover glass under the high-power objective (40X).
glabrata, Candida tropicalis, Candida dubliniensis, Observe morphological features of candida species.
Candida krusei, Candida parapsilosis. Therefore,
theaim of the present study isto differentiate the Candida Sugar Fermentation: Prepare liquid fermentation
species from type 2 DM patientsand todetermine the medium containing peptone (1%), sodium chloride
carbohydrate fermentation and assimilation tests, (0.5%), Andrade’s indicator (0.005%). Sterilize by
todeterminethe resistance to azole group. autoclaving at 120oC for 15 min at 15 pounds pressure.
Add filter-sterilized sugar at the concentration of 2% to
the medium. Pour into the sterile test tubes and place
Material and Method
sterile Durham’s tube into each tube. Plug the tubes with
This study was conducted in the Microbiology colour coded cotton plugs.
Department atSri Lakshmi Narayana Institute of
Inoculum preparation is done by suspending
Medical Sciences, Pondicherry. The study was approved
heavy inoculum of yeast grown on sugar free medium.
by the institutional ethical committee of Sri Lakshmi
Inoculate each carbohydrate broth with
Narayana Institute of Medical sciences, Pondicherry
approximately
according Helsiniki 1975 Human ethical guidelines.
0.1 ml of inoculum. Incubate the tubes at 25 oC up to 1
All the data were collected in a prescribed perform
week. Examine the tubes every 48-72hrs interval for
and obtained informed consent form from subjects. All
the production of acid and gas in Durham’s. Production
the oral wash samples received in the laboratory from
of gas in the tube is taken as fermentation positive
January to December 2016, smear positive for yeast
while only acid production may simply indicate that
were inoculated on Sabouraud’s Dextrose Agar (SDA).
carbohydrate is assimilated.
Colonies were identified as gram positive budding yeast
cells in Gram stain. Assimilation Test: Suspend a heavy inoculum of a 24-
48 hrs old yeast culture that has been subculture thrice
on
450 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 450
sugar –free medium in 2ml of Yeast Nitrogen Base. Add
this suspension to the 18ml of molten agar (cooled to 45 distinct colonies with approximately 5mm diameter. Then
o
C) and mix well. Pour the entire volume into a 90mm the colonies were suspended in 5ml of sterile
petri plate. Allow agar to solidify at room temperature. physiological saline and resulting suspension was
Place the carbohydrate-impregnated discs onto the agar vortexed thoroughly. The turbidity of the inoculum
surface.Incubate the plates at 37 oC for 3-4 days. The suspension was adjusted to 0.5 McFarland standard
presence of growth around the disc is considered as followed by inoculation of plates containing MHA
positive for that particular carbohydrate. supplemented with 2% glucose and 0.5μg/ml methylene
blue with a sterile cotton swab moistened with inoculum
Antifungal Susceptibility Test: The antifungal
suspension.
susceptibility testing of yeast isolates was carried out
using the disk diffusion method as per M44-A CLSI The plates were allowed to dry for 3-5 minutes and
guidelines (CLSI document M44-Aet al, 2004.). Mueller then antimicrobial discs were dispensed onto the surface
Hinton agar supplemented with 2% glucose and 0.5μg/ of inoculated agar plate. The discs tested were
ml methylene blue was used for sensitivity testing. The Fluconazole (10mcg), Amphotericin B
isolated Candida species were cultured on SDA at 35°C (50mcg),voriconazole (1μg) and Itraconazole (10mcg)
for 24 hours. Inoculums was prepared by picking with their zone diameters measured as per the instruction
five manual of manufacturer. All the media and discs were
procured from Hi Media Labs, Mumbai.6

Results

Table 1: Total Type II Diabetes mellitus and Gender distribution of oral candidiasis in Type II
DM
Total sample Positive Female Male
400 244 (61%) 129 (52%) 115 (47%)

Out of total, Candida species were isolated in 244(61%) patients. It was more significant in females129(52%)
than the males115(47%) in Type II diabetes mellitus

Table 2: Oral Candidiasis isolated in Alcoholic and non alcoholic of Type II DM

Male Alcoholic Nonalcoholic smokers Non smokers
115 98(85%) 1 7[15%] 89(77%) 26(23%)

Oral Candidiasis were higher in Alcoholic 98(85%) than the non alcoholic17[15%] among male Type II DM and
also Oral Candidiasis more significant in smoker 89(77%) in type II DM

Table 3: Denture and Non-denture in Type II DM

Total sample Denture Non-denture
244() 174(71%) 70(29%)

Oral Candidiasis were higher in Denture among Type II DM

Table 4: Candida species distribution in male and female patients

Spp Total n = 244 Female n:129 Male n = 115
C.albicans 135(55%) 69(53.4%) 66(57.3%)
C.tropicalis 43(17.6%) 26(20%) 17(14.7%)
C.dubilinesis 27(11%) 13(10%) 14(12.1%)
C.krusei 9(3.6%) 4(3.1%) 5(4.3%)
C.glabrata 15(6.1%) 9(6.9%) 6(5.2%)
C.paralopsis 15(6.1%) 8(6.2%) 7(6%)
Out of 244 samples, 135(55%)C.albicanswas isolated. In females C.albicans more significant followed by non–
albicans were C.tropicalis,bC.dubilinesi and C.glabrata.

Table 5: Candida species distribution in alcoholic, nonalcoholic patients, smoker and non smoker patients
Total Alcoholic Nonalcoholic Non smokers
spp smokers (n = 89)
(n = 115) (n = 98) (n = 17) (n = 26)
C.albicans 66(57.3%) 57(58.1%) 9(52.9%) 57(64.0%) 9(34.6%)
C.tropicalis 17(14.7%) 13(13.2%) 4(23.5%) 12(13.4%) 5(19.2%)
C.dubilinesis 14(12%) 11(11.2%) 3(17.6%) 10(19.1%) 4(15.3%)
C.krusei 5(4.3%) 4(4.0%) 1(5.8%) 2(2.2%) 3(11.5%)
C.glabrata 6(5.2%) 6(6. 1%) 0 4(4.4%) 2(7.6%)
C.paralopsis 7(6%) 7(7.1%) 0 4(4.4%) 3(11.5%)

Out of 115, 98 Candida species were isolated in alcoholic Type II DM Patients.C.albicans was higher in both
alcoholic and non alcoholic but varied in non albicans. C.glabrata and C.paralopsis not isolated in non alcoholic
patients. Out of sixty six C.albicans, 57were isolated in smoker and 9 were isolated in non smoker. Non albicans,
C.tropicalis was more significant followed by C.dubilinesi and C.glabrata

Table 6: shows the antibiotic susceptibility of Candida species

C.albicans C. dubilinces C. tropicalis C. krusei C. galabrata C. pralopsis

Anti fungal drug (n = 135) (n = 27) (n = 43) (n = 9) (n = 15) (n = 15)
S R S R S R S R S R S R
Fluconazole (10mcg) 112 23 21 6 32 11 7 2 10 5 12 3
Amphotericin B(50mcg) 42 80 13 12 14 28 1 5 6 9 2 12
voriconazole (1mcg) 59 67 16 9 20 17 5 3 7 6 9 4
Itraconazole (10mcg) 32 70 8 10 7 27 4 4 4 9 2 11
Out of the135 isolates of C. albicans,23 were and possibly increased glucose concentration in the
resistant to fluconazole, 80 wereresistant to saliva and gingival which might contribute in declining
amphotericine B,67 were resistant to voriconazole and70 pH of saliva resulting in acidogenic microorganism
were resistance toItraconazole. Of the 109 isolates of substrate and plaque formation [Table-1].
NCA, 66were more resistant to amphotericine B and
61were resistant to Itraconazole. Oral Candidiasis was more significant in females
129(52%) in the present investigation. which result
similar to the Khosravi AR, et al.study.11It has been
Discussion
found that elderly women presented more oral
Oral Candidiasis is one of the most common lesions,hormonal factor, iron deficiency in women
opportunistic mycotic infection which can occur broad- could be responsible for that disparity and this
spectrum antibiotics, antihistamines, radiotherapy, difference can be women seek dental treatment at a
diabetes, drug abuse, malnutrition, immune deficiencies higher rate than men.12
and old age.7 Diabetes mellitus is a major predisposing
factor to oral and symptomatic candidiasis.8 In present study,Candida is higher in
Alcoholic(85%) than nonalcoholic, this result agrees
In present study, prevalence of Candida carriers with L.D. Wilson et al,13 that Candida itself produces
in diabetes was 61% which is similar to that found in small quantity of alcohol as part of its metabolic. One
AkpanA and Talabani AN et al reported 9, 10, that due to Fifteen patients enrolled in the study were males,of
most of the microorganisms in the saliva are derived whom 89were Candida carriers in smokers. Therefore, it
from other parts of the oral cavity. The microvascular can be inferred that smoking was a relative risk factor
changes for presence of Candida in the oral cavity.14 [Table-2]
Javed et al. described more significant of oral species identification, antifungal susceptibility testing
Candida carriage associated with denture 74% with type and the development of new antifungal drugs are
2 diabetes. This results correlated in present study71%. mandatory to achieve a decrease in Candida infections.
Dentures act as an additional reservoir for these
organisms through the biofilm formation of Candida in Conflict of Interest: Nil
the oral cavity.15[Table-3].
Source of Funding: Self
Although, among the Candida species, C. albicans
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identified as C. dubliniensis. Willingeret al.17 also K, Sciepuk M, Zaremba ML. Occurrence rate of
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In present study C.albicans more resistant to
Method for antifungal disk diffusion susceptibility
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testing of yeasts; approved guideline. M44-A2
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8. Khaled H Abu-Elteen, PhD, Mawieh A Hamad,
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PhD,Suleiman A. Salah, PhD. Prevalence of Oral
The scores were slightly higher among the females as
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Chinna K; The prevalence of Candida spp. in the Klinge B, Engström PE. Periodontal conditions,
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DOI Number: 10.5958/0976-5506.2019.01612.7

Child Life Program Through Drawing Play Activity as Efforts

to Minimize Stress Hospitalization in Children with Leukemia

Yuni Sufyanti Arief1, IlyaKrisnana2, Praba Diyan Rachmawati2, Nursalam3, IDG Ugrasena4,
Shrimarti R. Devy5
1
Doctoral Student in Health Science, Public Health Faculty, Lecturer of Maternity and Pediatric Nursing
Department, 2Lecturer of Maternity and Pediatric Nursing Department, 3Lecturer of Fundamental
Nursing Division, Faculty of Nursing, 4Lecturer of Pediatric Division Medical Faculty, 5Lecturer in Public
Health Faculty, Universitas Airlangga, Surabaya, Indonesia

ABSTRACT
Background: Leukemia occupies 40% of all malignancies in children. A child who is diagnosed with
leukemia will undergo some procedure measures a long and painful. Nurses in nursing care in children
with various disorders of the body system of planned activities to minimize the stress of hospitalization that
occurs in children. Child Life Program is one of the interventions in nursing care in children to minimize
the impact stress of hospitalization and optimize growth and development in children. The purpose of this
study was to describe the effect of Child Life Program through drawing play activities to decrease the stress
of hospitalization in children suffering from Leukemia.
Method: This study was a quasi-experiment. The study population was children who suffering
from
leukemia are treated in the pediatric ward Soetomo Hospital.
Result: The result showed there is influence child life program through drawing play activity using “My
Activities Book” on the response to the stress of hospitalization of children before and after the intervention
with a p-value = 0.001.
Conclusion: Child life program through drawing play activity using “My Activities Book” can affect the
stress response of hospitalization in children with leukemia. Child life program through drawing play
activity using “My Activities Book” can be an alternative therapy that can be used to minimize the stress of
hospitalization in children with leukemia.

Keywords: Stress, Hospitalization, Child Life Program,

Leukemia

Introduction
1
Leukemia occupies 40% of all malignancies in
children. 1A child who is diagnosed with leukemia will
undergo some procedure measures a long and painful.
During the process of hospitalization due to Leukemia,
children and parents can experience handling a variety
Corresponding Author:
of events or actions that according to various studies
Yuni Sufyanti Arief, SKp., M.Kes
demonstrated the experience very traumatic and
Pediatric Nursing Division
stressful.2
Maternity and Pediatric Nursing Department
Psychological problems experienced by the child is
Faculty of Nursing Universitas Airlangga
in shock, stress, fear, anger, and depression. Nurses in
Surabaya Indonesia
nursing care in children with various disorders of the
Phone : +62812-3106-365
body system of planned activities to minimize the stress
Email: [email protected]
of hospitalization that occurs in children. Pediatric nurse
[email protected]
focuses on the psychosocial development of
children,
455 Indian Journal of Public Health Research
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Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 455

and promote effective coping strategies for children and asked to tell the picture and clarification child’s sense
their families who are experiencing stress. Child Life of the picture Companion more passive, listening, and
Program is one of the interventions in nursing care in paper facilities and equipment. Let children draw and
children to minimize the impact stress of hospitalization repeat this activity for days, until the child unknowingly
and optimize growth and development children. In the issuing its cargo amygdala, which express sadness,
Child Life Program showed individuality in patients, and depression, stress, creating images that make them
use a variety of developmentally appropriate activities, come back happy, and stir good times ever experienced
including Implementation of play activities, especially with their loved ones. Based on the above phenomenon
drawing on Pediatric ward Soetomo hospital still has not researchers interested in developing the Child Life
become routine. Drawing activity is expected to reduce program through play activities in childhood leukemia
the stress of hospitalization of children but until now as efforts to reduce the stress of hospitalization that
the effect of drawing activities to decrease the stress of occurs in children is leukemia.
hospitalization in school-age children still unclear.
Material and Method
Based on the observations of researchers during
the month of January 2013 in pediatric ward Soetomo The design of the study is quasi-experimental
hospital obtained the data that 70% of 10 patients aged which consists of treatment group and control group.
1-12 years who were treated at Soetomo Hospital during The study population was children who were diagnosed
the month, indicating negative behavior and most of with leukemia are treated in the pediatric ward Soetomo
the children showed maladaptive behavior, namely: hospital. Criteria for inclusion of children include 1)
100% of children are bored, lonely 75%, 62.5% to school-age children diagnosed with Leukemia, 2) get
be
hospitalization over 2 x in the pediatric ward Soetomo
withdrawn 25% whine and complain wants to go home,
hospital and 3) not in a critical condition. The
25% is angry. From the above data, it was concluded
independent variable in this study is child life program
that each preschool and school-age children who were
through drawing play (“My Activities Book”). The
treated in pediatric ward Soetomo hospital experience
dependent variable is a response to the stress of
stress of hospitalization.
hospitalization in children diagnosed with Leukemia.
Stress hospitalization is very dangerous for the The primary data was collected by observing and
survival of the child if not addressed can lead to recording the stress response of hospitalization of
impaired growth and development for children. Due to children before and after implementing drawing
sick and hospitalized, the child will lose the freedom activities. The instruments used in data collection in the
of view egocentric in developing autonomy. This will form of a checklist observation sheet models and
lead to regression and will eventually withdraw from structured interviews. Observation sheet that is used
interpersonal relationships.3 Increased cortisol in times contains 10 points positive response (adaptive) school-
of stress can inhibit antibody formation and reduce the age children to the stress of hospitalization modification
formation of white blood cells.4Decrease in antibody of the Wong (2009). The questions in the interview had
will reduce the body’s immunity. As a result, the healing been prepared in advance by researchers. The interview
process becomes obstructed, a longer treatment time, results will help researchers invalidating the results of
and increase the risk of complications during treatment. observations that have been made. The tools used for
activities drawing is drawing paper, pencils, and
There are various efforts in the Pediatric ward
crayons. The process of taking and collecting data in this
Soetomo hospital to reduce the stress of hospitalization,
study carried out after obtaining permission from the
one of them by implementing rooming-in. Activity has
also been given to play, but its implementation is still Soetomo Hospital to conduct research. As a first step the
not routine. The flurry of nurses and the lack of study, researchers will select respondents based on the
equipment is a reason for non-performance play predetermined inclusion criteria. After getting approval
activities. Drawing is one type of play activities that do from the children and parents, carried out preliminary
not require special attention from health workers. observations in both groups (intervention and control
groups) to identify the stress response hospitalization
Grown-up children can be asked to draw on experienced by children (Pre-test). If the pre-test found
their the child with an adaptive stress response (≥ 50%),
likes and dislikes of hospitalization. Then children were
children continue to be included in the study. Later Result and Discussion
in the treatment group was given intervention in the
Results of the characteristics of respondents by sex
form of activities drawing made in the “My Activities
show the number of male respondents as many as 6
Book”. Themes my activity drawing in the book include people (43%) and women of 8 people (57%).
the theme of knowledge about animals and plants. At Characteristics of respondents by age indicates the
the first meeting of researchers and teams carry out number of respondents by age 3 years as many as 6
interventions to deliver a game program which is given people (43%), 4 years as many as 8 people (57%). Table
to children by involving parents. After the first meeting 1 shows the characteristics of respondents based on the
of the researchers provide “activity books” to each stress response of hospitalization shows the results of the
respondent to continue doing coloring on “My Activities pre-test assessment maladaptive stress of hospitalization
with the interpretation of 8 people (57,14%) and
Book”. Independent activity, accompanied by parents
adaptive as many as 6 people (42.8%). While the post-
was conducted along 2 weeks. At the end of the second-
test results of the stress response hospitalization
week researchers conducted observations about stress assessment obtained as many as 12 people (85.71%)
response experienced by the child’s hospitalization. adaptive response and as many as 2 respondents with
interpretation maladaptive (14.28%).

Tabel 1: Hospitalization stress response preschoolers at Hematology Bona II ward

Pre Test Post Test
Respondent
score Response score Response
1. 36.3 Adaptive 9.09 Adaptive
2. 36.3 Adaptive 9.09 Adaptive
3. 81.81 Maladaptive 81.81 Maladaptive
4. 18.18 Adaptive 63.63 Adaptive
5. 81.81 Maladaptive 27.27 Adaptive
6. 90.9 Maladaptive 63.6 Adaptive
7. 27.27 Adaptive 36.36 Adaptive
8. 45.4 Adaptive 9.09 Adaptive
9. 100 Maladaptive 100 Maladaptive
10. 36.3 Adaptive 18.18 Adaptive
11. 72.7 Maladaptive 27.3 Adaptive
12. 72.7 Maladaptive 9.09 Adaptive
13. 81.8 Maladaptive 9.09 Adaptive
14. 81.8 Maladaptive 45.4 Adaptive
Wilcoxon Signed Rank Test p = 0.001
After the analysis, part of this discussion will be to the stress of hospitalization. Based on pre-test results
reviewed on the Child Life program through drawing showed at most have a maladaptive response category as
play activities against hospitalization stress response many as 8 people (57.14%). After the play therapy using
toddler and preschool-aged children with cancer in “My Activities Book” do post-test to measure the child’s
pediatric ward Soetomo Hospital. Based on statistical response to the stress of hospitalization. Based posttest
tests, there is the effect of play therapy using “My results in Table 1, the result of 12 respondents (85.71%)
Activities Book” on the response to the child’s had an adaptive response category.
hospitalization. Statistical tests are showing that there
was a significant effect of play therapy using “My Based on statistical results indicate the value of p =
Activities Book” on the stress response of children. 0.001, which means p <0.05, then there is the influence
of the child life program with play therapy using “My
Before the play therapy using “My Activities Activities Book” to the child’s response to the stress
Book” do the pre-test to measure the child’s of hospitalization before and after the intervention.
response
The above in accordance with the expression Alice D. Aspects of language have the lowest value among
Domar, about the benefits of the diary as a step to other aspects, the average participant is unable to utter
express emotions and feelings as well as helping to take his willingness to follow the activities. There are several
care of our minds. According to Piaget (1962) in things that can affect this, such factors preschool age
Tedjasaputra (2001), preschool children are already children who are still in the stage of development and
using objects as symbols. This symbol is getting to be a sense of initiative versus guilty. Children to be afraid
closer to the fact that the exercise of thinking and and shy to express its readiness to follow the therapy.
directing the child to adjust to the environment (Sari, In addition, the ability of researchers to carry out
2013). therapeutic communication also need to be increased
to stimulate the child express feeling. The increasing
The impact on children aged toddler due to
of adaptive response in children given treatment in
hospitalization include separation anxiety, loss of
accordance with the theory of Nursalam (2005) in
freedom in the development stage, as well as feeling
which the player can reduce the pressure or stress on
hurt because of injury due to invasive, often arise due to the environment. Through playing children can express
the child’s hospitalization.5 In the two respondents who emotions and discontent will be something on the social
have a maladaptive response in pre-test increased to situation and fears that can not be expressed in the real
adaptively during post-test. Improved balanced and world. Playing well is something that naturally existing
adaptive response in children because children are given in one’s children. At the time of play therapy using a
daily intervention play therapy by researchers. In book researcher expression and give trust approach to
therapeutic play therapy nurse to establish the child so that the child believed to nurses, the nurse
communication with the child, in addition to the nurse then explores the child’s feelings and provide play
also meet the needs of children who play more or less therapy in the form of coloring, writing and reading fairy
disrupted by the impact of the activity book. The user tales. It is based on the function of play that has
can increase a child’s response to the stress of therapeutic value in providing a release of stress and
hospitalization in some aspects, aspects of the evaluation tension, encourage experimentation and testing of a
sheet wong unchanged from become maladaptive scary situation in a safe manner, facilitate direct
response adaptive response and retain the adaptive communication is not verbal and non-verbal about the
response of children to remain to respond adaptively to needs of fear and desire. Another thing that affects
the stress of hospitalization. children, namely frequency adaptation response of
children with hospitalization average more than 3 times,
Another aspect examined in this study is the so that children tend to be more familiar and easier to
cognitive, affective, psychomotor and language. Daily adapt to the hospital environment. Children become
observation sheets show attendees on the cognitive more easily increase their adaptive behavior against the
aspects, there are several respondents who have a low stress of hospitalization.
score, it indicates that the respondents were not able
to mention the expression as given intervention, this The results of observations of the children who are
happens because the participants are still in the stage given treatment, children tend to be more reliant on
of trust with researchers, when intervention has been nurses. Children are also more cooperative after the play
running for more than three days almost all participants therapy using expression books. According to interviews
demonstrated the ability to express his feelings. In the with the parents of patients, children are given play
psychomotor aspects of participants has been good, just therapy also became more cheerful and rarely cried.
on some of the participants have a value lower scores. Thus the play therapy with the use of media expression
This is because of the short duration of treatment of books has an influence on children’s level of adaptive
patients, so when compared to the other participants responses to the stress of hospitalization.
with a longer duration of treatment relatively low value
of some participants. On one of the participants obtained Conclusion & Recommendation
scores on all aspects of this is due to the low physical
Conclusion: Child Life program through play activities
condition of participants were less good. On some days draw with media “My Activities Book” can affect the
the intervention patients had a fever thus decreasing the stress response of hospitalization in children with
willingness of participants to take part. leukemia.
Recommendation: Based on the results of the research, 6. Arikunto S. Prosedur Penelitian Suatu Pendekatan
advice that can be given is 1) Nurse on duty at Space Praktik. Jakarta, PT: Rineka Cipta ; 2010.
Bona II is expected to implement a media play therapy
7. Dharma, K.K. Metodologi Penelitian
with “My Activities Book” in children with cancer to
Keperawatan. Jakarta, JKT: CV. Trans Info
minimize the stress of hospitalization in the room, 2)
Media: 2011.
the field of nursing Hospital Dr. Soetomo expected to
meet the appropriate human resources in space Bona 8. Damanik, E. D. Pengujian validitas dan
II in order to carry out the fullest play therapy because reliabilitas analisis item dan pembuat norma dass:
of limited power in the chamber. 3) To further study of Penelitian pada kelompok sampel Yogyakarta
child life therapy program developed using variables dan Bantul yang mengalami gempa bumi,
such research other variables in the development of 2010. Available at
children with cancer. http://www.digilib.ui.ac.id/opac/themes/libri2/
detail.jsp?id=94859. Acessed 21 Februari 2012.
Conflict of Interest: The authors declare that they have
no conflict of interest. 9. Hus, M.A. Parents and Children Coping
with Pediatric Cancer: Associations Between
Source of Funding: This research obtained funding Parent and Child Anxiety, and Parent-Child
from the Faculty of Nursing University of Airlangga Communication. Thesis. Nashville Tennessee:
Surabaya Vanderbilt University; 2009.

Ethical Clearance: This research has obtained the 10. Kazak, E.A. Evidence-Based Interventions
approval of ethical conduct from the Soetomo Hospital’s for Survivors of Childhood Cancer and Their
ethical committee of Surabaya with number 385/ Families.Journal of Pediatric Psychology2005.
PankeKKE/V/2017 30(1), Available at http://jpepsy.oxfordjournals.
org. Accessed 8 December 2011.
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DOI Number: 10.5958/0976-5506.2019.01613.9

The Correlation between Diabetes Status and Hair Loss among

Aged Women in Alor Setar Area

Thin Thin Aung1, Fatin Farhana Binti Shahnon2

1
Senior Lecturer, 2BMS Student, International Medical School, MSU)

ABSTRACT
The aim of this study was to identify the diabetes among aged women in Alor Setar area and to compare
association between diabetes and current hair loss condition. Across sectional study was conducted to study
the prevalence between diabetes and hair loss among aged women around Alor Setar area. Primarily data
was collected using interviewer-administered questionnare consisting of socio-demographic questions for
part A-the aged of the women, employment status and diabetes status. Stress level for part B and the hair
loss scale for part C.As a part of population based on cross sectional study, the hair status of 112 aged
women range 50-60 years was assessed by answering questionare,56 from them suffered with diabetes and
another
56 of them non-diabetes. The aged women with yes diabetes status have a highest prevalence of excessive
hair loss which is 93.6% compare to non-diabetes aged women with excessive hair loss is 6.4%.Based on
the table aged women who are non-diabetes have high prevalence hair loss in moderate hair loss which is
69.7% compared to women with diabetes status and experiencing hair loss which is 30.3%. Besides, the
prevalence of non-diabetic aged women with normal hair loss is high which is 93.8% compared to diabetic
aged women who experiencing normal hair loss is 6.3%. The result from this table showed that the P value
is 0.000. The P value is less than 0.01. So, the null hypothesis for fifth objective rejected. Thus, there is
significant relationship between diabetes status and hair loss. The result supports the hypothesis that aged
women with diabetic experiencing hair loss.

Keywords: Aged women, Diabetes, Hair loss.

Introduction and the Western Pacific. During pregnancy high blood
glucose substantially increases the risk to health for both
Diabetes mellitus is a group of metabolic and
mother and child as well as the risk of diabetes for the
chronic disease caused by inherited and/or acquired
child in the future. Almost half of women who die in
deficiency in production of insulin by the pancreas. It is
low-income countries due to high blood glucose die
characterized by hyperglycemia which in turn damage
prematurely, before the age of 70 years. (World Health
many of the body’s systems, in particular the blood
Organisation,2017).
vessels and nerves. (American Diabetic Association,
2009) and On World Diabetes Day 2017, WHO joins There are other causes of hair loss linked to
partners around the world to highlight women’s right to diabetes that could be an issue here, too. For instance,
a healthy future. Around 8% of women or 205 diabetes can affect your circulatory system, making it
million women live with diabetes worldwide, over less effective (2). As certain nutrients and proteins are
half in South-East Asia essential for hair growth, a decrease in the amount of
these reaching hair follicles could result in weaker and
slower hair growth(1) . A simple way to remedy this is
Corresponding Author: to start taking a nutritional supplement which does not
Dr. Thin Thin Aung have a sugar coating. This will ensure the body is getting
Management & Science University (MSU) a consistent level of nutrients in case diet alone does not
University Drive, Off Persiaran Olahraga, provide a sufficient amount. If you’re feeling unwell
Section 13, 40100 Shah Alam, or have other unexplained symptoms alongside your
Selangor Darul Ehsan, Malaysia hair loss, you may be suffering from an infection,
Phone: 01-23767078 as
460 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 460

diabetes can affect your immune system when the blood will be done, is geographically having a marking of north
contains excess sugar(4). An infection can disrupt the hair Malaysia. Alor Setar has some administrative
growth cycle, causing hairs to go into their resting phase importance, thus it becomes quite busy during weekdays
prematurely, leaving you with weaker hair (22). (The
and in the weekends. There are many villages around
Belgravian Centre, 2015).
here and urban area based on the previous research, also
The literature reveals what little is known about they have done. Thus, it had been the solid reason for the
nutritional factors and hair loss. What we do know study, focusing most intensively on this surrounding area.
emanates from studies in protein-energy malnutrition,
Study Population: The option of the calculation
starvation, and eating disorders. In otherwise healthy
formula is based on the objective which is to study the
individuals, nutritional factors appear to play a role in
correlation between diabetes aged women and hair loss.
subjects with persistent increased hair shedding (6).
The most suitable formula for this objective is “Single
Excessive intakes of nutritional supplements may Population Proportion” formula. From a previous study
actually cause hair loss and are not recommended in by (Jaykaran Charan and Tamoghna Biswas, 2013),
the absence of a proven deficiency (17). While nutritional the expected prevalence for the results are 50%, so by
factors affect the hair directly, one should not forget implicating the formula given, the estimated sample
that they also affect the skin (18). In the management of size for this research are approximately 112 people. The
subjects with hair loss, eliminating scaling problems is sample size is calculated as followed by the formula.
important as is good hair care advice and the need to
Data Analysis: Data that obtained during the study was
explain fully the hair cycle. Many individuals reduced
entered, sorted and analyzed by using Statistical Package
their shampooing frequency due to fear of losing more
for Social Science (Version 21). The descriptive
hair but this increases the amount seen in subsequent
statistics includes the mean, standard deviation,
shampoos their fear of going bald and adversely
frequency, and percentage. This descriptive analysis was
affecting their quality of life(21).( D. H. Rushton,2002).
used to analyze the social demographic, between hair
The research studied 20 premenopausal women loss and diabetes and between stress level and hair loss
with female pattern hair loss and 9 healthy women among aged women. Later, the results obtained, had
for serum levels of LH, FSH, estradiol, free and total been presented in words and depicted in tables as well as
testosterone, sex hormone binding globulin (SHBG) graph.
and dehydroepiandrosterone sulfate (DHEAS) on the
first day of their menstrual cycle. it is the estrogen to Table 1: Socio-Demographic Studies of Respondents
androgen ratio, as represented by the ratio of estradiol to
Frequency
free testosterone that might be responsible for triggering Variable Answer
female pattern hair loss in women(2).( Riedel A,2008). N %

Diabetes Diabetes 56 50.0

Materials and Method Status Non- Diabetes 56 50.0

Study Design: This is an observational analytical Employment Employed 42 38.0

cross-sectional study where all the results are measured Status Unemployed 70 62.0
concurrently in a given population at a short period Normal 96 68.0
of time. This type of study design will be used in Stress Level Mild 35 31.0
determining the diabetic status and hair loss and stress
Moderate 1 1.0
level among Aged women in Alor Setar area.
Normal 32 29
Sampling Area: This research study had been conducted Hair Loss Moderate 32 29
around the Alor Setar area, from which the data
collection Excessive 47 42
Table II: To Investigate the Correlation between Diabetes Status and Stress Level

diabetes status * stress level Cross tabulation

stress level
Normal mild Total
moderate
Count 33 23 0 56
% within diabetes status 58.9% 41.1% 0.0% 100.0%
Yes
% within stress level 43.4% 65.7% 0.0% 50.0%
% of Total 29.5% 20.5% 0.0% 50.0%
Diabetes status
Count 43 12 1 56
% within diabetes status 76.8% 21.4% 1.8% 100.0%
No
% within stress level 56.6% 34.3% 100.0% 50.0%
% of Total 38.4% 10.7% .9% 50.0%

Table III: To Investigate the Correlation between Stress Level and Hair Loss

stress level * hair loss Cross tabulation

hair loss
Absent/normal moderate Total
Excessive
Count 26 20 30 76
% within stress level 34.2% 26.3% 39.5% 100.0%
Normal
% within hair loss 81.3% 60.6% 63.8% 67.9%
% of Total 23.2% 17.9% 26.8% 67.9%
Count 6 13 16 35
% within stress level 17.1% 37.1% 45.7% 100.0%
Stress level Mild
% within hair loss 18.8% 39.4% 34.0% 31.3%
% of Total 5.4% 11.6% 14.3% 31.3%
Count 0 0 1 1
% within stress level 0.0% 0.0% 100.0% 100.0%
Moderate
% within hair loss 0.0% 0.0% 2.1% .9%
% of Total 0.0% 0.0% .9% .9%

Table IV: To Investigate the Correlation between Diabetes Status and Hair Loss

diabetes status * hair loss Cross tabulation

Hair Loss Total
Absent/Normal Moderate Excessive
Diabetes Status Yes Count 2 10 44 56
% within diabetes status 3.60% 17.90% 78.60% 100.00%
% within hair loss 6.30% 30.30% 93.60% 50.00%
% of Total 1.80% 8.90% 39.30% 50.00%
No Count 30 23 3 56
% within diabetes status 53.60% 41.10% 5.40% 100.00%
% within hair loss 93.80% 69.70% 6.40% 50.00%
% of Total 26.80% 20.50% 2.70% 50.00%
To Observe the Correlation Between Employment
Status and Stress Level among Aged Women: The
results of the analysis confirmed the first hypothesis that
the prevalence of employment among aged women is
associated with hair loss among aged women. A healthy
job is likely to be one where the pressures on employees
are appropriate in relation to their abilities and resources
to the amount of control they have over their work and
to the support they receive from people who matter to
them. As health is the absence of disease or infirmity but
a positive state of complete physical, mental and social
well-being (WHO, 1986). However some abilities,
including strength and mental agility decline in most
people over a certain age, but much less and much later
Fig 1: Correlation Between Diabetes Status And than many people think.
Hair Loss Graph
To Investigate the Correlation between
Employement Status and Hair Loss among Aged
Results Women: It was already asked and stated inside the
Discussion questionnaire where they were prior to answer that
Data from this study showed that there was question. Therefore, we analyzed the prevalence of
relationship between the correlation of diabetes status each employment status that associated with hair loss.
and hair loss. These variables associated between The result is not significant because the respondent that
diabetes statuses aged women with yes diabetes status suffers with hair loss not only the employed aged
have a highest prevalence of excessive hair loss which women but also the unemployed experiencing with hair
is 93.6% compare to non-diabetes aged women with loss. So the result is not significant.
excessive hair loss is 6.4%.Based on the table aged To Investigate the Correlation between Diabetes
women who are non-diabetes have high prevalence hair Status and Stress Level: From this research study,
loss in moderate hair loss which is 69.7% compared analysis between prevalence of related diabetes status
to women with diabetes status and experiencing hair with stress level showed that aged women with non-
loss which is 30.3%. Besides, the prevalence of non- diabetes status have a highest prevalence of normal
diabetic aged women with normal hair loss is high stress level compare to diabetes aged women with
which is 93.8% compared to diabetic aged women who normal stress level. The result from this table showed
experiencing normal hair loss is 6.3%The result from that the p-value is 0.056. So, the null hypothesis for third
this table showed that the P value is 0.000. The P value objective failed to reject. Thus, there is no significant
is less than 0.05. So, the null hypothesis for fifth relationship between diabetes status and stress level.
objective rejected. Thus, there is significant relationship
between diabetes status and hair loss. To Investigate the Correlation between Stress Level
and Hair Loss: The result from this showed that the
Furthermore, this research had been proven that this p-value is 0.286. So, the null hypothesis for third
cross-sectional study had linked the diabetes status and objective failed to reject. Thus, there is no significant
hair loss among aged women. Hair usually goes through relationship between stress level and hair loss because of
three phases. During the active growing phase, which women with high stress level experiencing hair loss and
lasts for two years or more, hairs grow at a rate of 1 to 2 women with normal stress level also experiencing hair
cm per month. Hair then goes into a resting phase, loss.
which lasts for about 100 days. After this phase, some
of the resting hair falls out. Diabetes can interrupt this Conclusion
process, slowing down the hair growth. The immune
system is affected when blood sugar level rises above From this study, it can be concluded that diabetes
normal. As a result, people with diabetes are at an status had given a variation of results. According to the
increased risk for developing an infection and the body findings, there was relationship between the correlation
is less capable of fighting it. (Belgravia Centre, 2011) of diabetes status and hair loss. These variables
associated aged women with yes diabetes status have
a highest
prevalence of excessive hair loss which is 93.6% with male pattern baldness. J Invest Dermatol.
compare to non-diabetes aged women with excessive 2001;116:452
hair loss is 6.4%.Based on the table aged women who
6. Calvo RM, Asunción M, Sancho J, San Millán JL,
are non- diabetes have high prevalence hair loss in
Escobar-Morreale HF. The role of the CAG repeat
moderate hair loss which is 69.7% compared to women
polymorphism in the androgen receptor gene
with diabetes status and experiencing hair loss which is
and of skewed X-chromosome inactivation, in
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the pathogenesis of hirsutism. J Clin Endocrinol
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Metab. 2000;85:1735-40.
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Conflict of Interest: We certified that there is no
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conflict of interest with any financial organization
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regarding the material discussed in the manuscript.
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DOI Number: 10.5958/0976-5506.2019.01614.0

Differences in Caries Prediction Test of Cariostat and Plaque

Formation Rate Index (PFRI) on Children

Prima Nerito1, Boy Sandy Sunardhi1, Tito Yustiawan2

1
Department of Health Administration and Policy, 2Lecturer of Department of Health Administration
and
Policy, Faculty of Public Health, Airlangga University, Surabaya, Indonesia

ABSTRACT
Background: Dental caries is an irreversible dental disease. The incidence of dental caries in children
was increased by 60-90%. Dental caries can be recognized by various factors. Caries risk status needs
to be adjusted so that caries development can be inhibited as early as possible. Methods of caries risk
measurement are PFRI and cariostat caries prediction. The aim of this study was looked at the risk factors
of childhood caries by using combination of PFRI and Cariostat.
Method: This study was an observational analytic study with laboratory study approach. Based on the
time it was the cross sectional study. The samples were 36 children in TK Maryam Jl. Manyar Sambongan
Surabaya. This study was used primary data, then the data were analyzed in Microbiology Laboratory of
FKG Airlangga University Surabaya. Data analysis was conducted with Kolmogorov-Smirnov and
Spearman Correlation.
Results: There were 12 children suffered high dental caries (>5), 12 children suffered moderate dental
caries (3-4), 12 children suffered low dental caries (0-2). Measurement of caries risk used Cariostat and
PFRI was showed a strong correlation (p>0.05)
Conclusion: The correlation of caries risk test score using Cariostat caries activation test and PFRI
that
correlated with deft index are has no different results

Keywords: Dental Caries, Child, Cariostat, PFRI

Introduction Email: [email protected]

Dental caries is an irreversible tooth disease. World

Health Organization (WHO) in 2007 in Suciari et al
(2015) states the incidence of dental caries in children
increased by 60-90%10. The survey conducted by the
Ministry of Health of Republic Indonesia on the 3rd and
4th Five-Year Development Plan, shows the
prevalence
of Indonesian population who suffered dental caries
by
80% and 90% whom of them are the group of under-five
children. According to Antara News quoted by Maulani
and Jubilee (2005), the number of under-five
children

Corresponding Author:
Prima Nerito
Department of Health Administration and Policy,
Airlangga University, Surabaya
Street of Dr. Ir. H. Soekarno, Mulyorejo, 60115
in Indonesia reaches 30% of 250 million Indonesia’s
population, so it is estimated that under-five children
who suffered dental damages reaches 75 million more7.
The addition of the sufferer number is really possible.
This can be seen from the National Household Health
Survey (SKRT) in 1990 by 70% to 90% in 20036. Based
on the health survey results, prevalence of dental caries
by age group, i.e. 3 years old (60%), 4 years old (85%)
and 5 years old (86.4%). Those groups of under-five
children are susceptible to dental caries8.

Prevention of dental caries is more important

conducted early. The conducted prevention should be
in accordance with the factors that cause dental caries.
Factors that cause dental caries in children may come
from both of internal and external. Internal factors
include plaque quality, caries-causing bacteria such as
Streptococcus mutans, etc. while external factors such as
foods and the ability of children to brush teeth.
466 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 466

A person’s caries risk status is important to and PFRI. Then the data was tested with normality and
conducting measuring so that caries development can correlation analysis test.
be inhibited as early as possible. The available
methods to measure the caries risk are various. This Prior to conduct the correlation analysis test, the
shows the existence of development on caries risk normality test of data was performed using
measurement method. A measurement method should Kolmogorov- Smirnov. Table 1 shows that data in
meet several requirements such as provide accurate Cariostat has value greater than 0.05 (p>0.05) which
results, have high specificity and sensitivity, simple, low- means that the data is normally distributed, while the
cost, and not require special tools (Hesty, 2007). Methods data on deft index and PFRI are less than 0.05 so that the
that can be used in measuring caries risk are Plaque data is abnormally distributed. Then it was proceeded
Index, PFRI (Plaque Formation Rate Index), colony with Spearman correlation test to see correlation
calculation of Streptococcus mutans, etc. Plaque Index between deft index and both of caries risk test i.e.
and colony calculation of Streptococcus mutans are the Cariostat and PFRI.
calculation of caries risk that are done at any time so
they will produce numbers that can be influenced by
many things. While the external factors can be controlled Table 1: Normality Test of Data using
by using PFRI. Plaque calculations using PFRI provide Kolmogorov- Smirnov Test
an objective number for viewing plaque formation Deviation Normality
without being influenced by external factors. The No. Group Mean
standard test
combination of caries risk factor measurements PFRI Deft
and seeing the amount of Streptococcus mutans by using 1 5.6111 5.8665 0.009
Index
cariostat can provide a more accurate description in
2 Cariostat 1.19 0.920 0.051
determining one’s caries risk factors. This study aims to
look at risk factors for childhood caries by using 3 PFRI 2.17 1.159 0.007
combination of PFRI and Cariostat.
Table 2: Value of Significance and Correlation
Method Coefficient between Deft Index with Cariostat and
Deft Index with PFRI
The type of research used in this study was
analytical observational using cross-sectional research Significance
Coefficient
design with laboratory study approach. The research of
of
was conducted at Maryam Kindergarten Jl. Manyar No Correlation Correlation
Correlation
Sambongan, Surabaya and the analysis was conducted at Test with
Test
FKG Microbiology Laboratory of Airlangga University. Deft
The inclusion criteria of respondents consist of children 1. Correlation
aged 4-5 years, have no permanent teeth, all deciduous between Deft
teeth have erupted, have no systemic disease, and not Index with
0.000 0.857
consume drugs. Data analysis was done using statistic Cariostat Score
approach with Kolmogorov-Smirnov normality test, 2. Correlation
then it continued by correlation test using Spearman between Deft
Correlation. Statistical data analysis is presented using Index with
0.000 0.818
Statistical Product and Service Solutions (SPSS) 20.0 PFRI Score
for Windows.

Results
Clinical examination conducted on 36 children
in Maryam Kindergarten Surabaya, it was found 12
children suffering high dental caries (>5), 12 children
suffering moderate dental caries (3-4), and 12 children
suffering low dental caries (0-2). Measurements of Graph 1: The Relationships of Cariostat and PFRI
caries risk in 36 children were conducted using cariostat with Deft Index of Children’s Caries Aged 4-5 Years
Table 2 discloses that the significant value between A longitudinal study has been done by Roxana
Cariostat and Deft Index is <0.05 that has value p = Vacaru in Romania to look at the factors of caries risk
0.000 with correlation coefficient by 0.857. This is by using PFRI. The study was conducted on 139
indicates that Cariostat has strong correlation value. children who were in the age of 6-14 years whom
While the significant value between PFRI and Deft
examined the value of deft and also the value of PFRI.
Index is 0.000 with correlation coefficient by 0.818. This
Researchers divide into 3 groups, those are the low risk
is indicates that PFRI also has strong correlation. The
group that is PFRI 1-2, the risky group that is PFRI 3
above calculations show that caries risk measurements
using both of Cariostat and PFRI are have strong and the high risk group that is PFRI 4-5. After 2 years
correlation values. the deft value of the research sample was calculated and
it was correlated with the PFRI value. The results of this
study are caries prevalence in children was conforming
Discussion
to factors of caries risk calculated by PFRI. Children
The caries risk is a person’s probabilities to with low-risk factors of caries had low-prevalence of
having carious lesions in a given time period while the caries, while children with high-risk factors had
measurement of caries risk is an important preventive high-prevalence of caries. This was indicates that PFRI
steps to get good dental and mouth hygiene by is effective for predicting caries incidence in children 9.
identifying factors of caries etiology5. Measurement of
caries risk is done as early as possible so that caries A longitudinal study was also performed by Perr
prevention can be done. There are various ways in Axelsson to look at the caries growth across different
determining factors of caries risk, there which were age groups. This group is divided into ages of 0-2 years,
using specific materials as the tools, and there which 5-7 years and 11-14 years. Each group was measured
were not using certain materials or tools. The way of PFRI value and deft value. The result of PFRI and deft
measuring caries risk that using plaque samples are value show that there are relationship between the high
Cariostat and PFRI that are easy to do in children.
value of PFRI and the prevalence of caries on children.
The correlation tests of Cariostat score with deft Then Axelsson created a caries prevention program
index and PFRI score with deft index were performed according to the group of caries risk factor. The results
in this study. The result of this research is the correlation of the program were seen 20 years later and a small
between cariostat score with deft index is stronger than prevalence score was found in these children. This was
PFRI score with deft index. indicates that PFRI is effective for used as a predictor for
determining caries prevention steps on children 3.
PFRI using plaque samples that aim to see the
growth of plaque on each individual. This index is Cariostat is used plaque samples to determine
useful to see factors of caries risk caused by plaque the caries risk in patients. pH of plaques taken on the
growth. This index includes plaque throughout the patient’s teeth, incubated 48 hours so that bacteria in the
surface of the tooth except occlusal which is seen after
plaque fermented the sugar on the medium. The acid
24 hours without any cleaning done. Accurate results
produced by bacteria on the medium will change the
will be obtained if the subjects’ teeth previously cleaned
color on the medium so that the degree of acidity in the
by professionals 2 .This index has the advantage that is it
is not need special tools then it can be done with plaque can be measured.
minimal cost. However, measurement of this index is Acid production on dental plaque is an important
require the cooperation of patients as well as the
caries risk factor because dental caries is initiated by
patient’s parents to keep the patient from performing
demineralization on teeth surfaces by organic acids that
dental and oral cleansing within 24 hours.
were produced by bacteria in dental plaque. Previous
PFRI has objective results because cleaning is done studies reported that after rinsing with sugar, dental
by professionals so that initial plaque of each child is plaque acquired in active caries patients showed a lower
standardized from 0. The resulting PFRI value is purely last pH than inactive caries patients. This suggests that
from the plaque growth pattern of each child without examination of pH on dental plaque is one of the steps to
being influenced by children’s knowledge, how to brush measure caries risk (Shimizu, 2008).
their teeth, etc.
A longitudinal study was conducted by Tsubouchi in difference between the results of risk test scores by
Okayama, Japan to evaluate predictive value in Cariostat. using
The study was conducted on 100 children who
participated in routine dental checkups at 18, 24, and 36
months. The results of the study were caries prevalence
in children aged 18 months by 9%, children aged 24
months by 21%, and children aged 36 months by 70%.
Cariostat scores in each age were correlated with the
respective deft index. The Cariostat scores on each age
show the good validity. This suggests that Cariostat is
effective in predicting caries incidence in children (Berg,
2006).

In this study, both of Cariostat and PFRI are have

high correlation coefficient to the deft index. The
previous research has also shown that both of PFRI
and Cariostat can be a tool for predicting factors of
caries risk. However, both of these measuring tools
have disadvantages and advantages. Cariostat has the
disadvantages of requiring special materials that are
costly and requiring special tools such as incubator.
The results will be seen after 2 days because they
require an incubation time to get the test results (Rodis,
2005). Whereas the advantages of Cariostat is the quick
and easy application in patients. So that Cariostat is
appropriate for the children who are less cooperative or
children with special needs, because it does not take a
long time or a certain way to take plaque samples.

PFRI also has its own advantages and

disadvantages. The disadvantages of PFRI are the
operator should clean the patient’s teeth on the first
day, ensure the plaque value of patient is 0 and then
measure the plaque value
24 hours later and re-clean the patient’s plaque. This is
less appropriate when conducted for non-cooperative
children who do not want to open the mouth in the long
time. However, the advantages of PFRI are its low cost
because it does not require a certain tool or material. In
addition, PFRI is also advantageous for patients due to
they get dental cleaning that performed by the operator.

Dental caries is a multifactorial disease. Other

factors such as dental and mouth hygiene, carbohydrate
intake, and amount of Streptococcus mutans bacteria
were contributed to dental caries. By combining the
measurement of caries etiology factor in the patient,
then the determination of caries risk would be more
appropriate so that caries prevention can be performed
effectively although the high cost will be needed 1.

The conclusion of this study is there was

no
caries activity test both of Cariostat and PFRI which
is
correlated with the deft index.

Conclusion

The conclusion of this study is there was no

difference between the results of risk test scores by using
caries activity test both of Cariostat and PFRI which is
correlated with the deft index. PFRI can use as a cheap
and easy tool to predict caries in children. Predicting the
risk of caries is important to make free caries teeth.

Ethical Clearance: Taken from ethic committee of

faculty of dentistry, Airlangga University.

Source of Funding: Self Funding

Conflict of Interest: There aren’t any relevant conflict

of interest

REFERENCES
1. Axelsson, Per. 2000. Diagnosis and Risk
Prediction of Dental Caries. Vol 2. Chicago:
Ouintessence Publishing Co, Inc.
2. Axelsson, Per. 2005. The Effect of a Needs
Related Caries Preventive Program in Children
and Young Adults-Results after 20 Years. Seattle,
USA: BMC Oral Health.
3. Axelsson, Per. 2006. The Effect of A Needs
Related Caries Preventive Program in Children
and Young Adults-Results after 20 Years. Seattle,
USA: BMC Oral Health.
4. Berg, J and Slayton, RL. 2006. Early Childhood
Oral Health, Willey Blackwell. Singapore.
5. Hausen, H, et al. 1994. Can Caries be Predicted.
Textbook of Clinical Cariology. Copenhagen:
Munksgaard.
6. Healthy Department of Republic Indonesia, 1990.
Household Health Survey (SKRT) 1990. Jakarta:
Agency for Health Research and Development.
7. Maulani, Chaerita and Jubilee, Enterprise. 2005.
Tips for Caring Children’s Teeth. p.71,125.
Jakarta: Elex Media Komputindo.
8. Riyanti, E, et al. 2009. Prevalence of Nursing
Mouth Caries in Children Ages 15-60 Months
Based on Frequency of Brushing Teeth. Bandung:
Padjadjaran University.
9. Roxana, S, et al. 2003. Clinical Preventive http://journal.unair.ac.id/download-fullpapers-
Strategies for Children and Adolescents pmnj5ab2f127c22full. pdf on March 6, 2018
Identified as at High Risk of Developing Caries. at
International Journal of Paediatric Dentistry. 08:03 p.m.
Volume 21, 167-174.
11. WHO, 2007. WHO Oral Health Country/Area
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accessed via 6, 2018 at 08:38 p.m.
DOI Number: 10.5958/0976-5506.2019.01615.2

Customers’ Service Expectations in Dental Hospital:

Using Servqual Model

Firdauzi Rimadhan1, Devita Tintasari1, Fredy Mardiyantoro2

1
Student of Health Policy Administration Program Study, Faculty of Public Health, Airlangga
University;
2
Lecturer of Oral and Maxillofacial Surgery, Faculty of Dentistry, Brawijaya University, Indonesia

ABSTRACT
Background: In the health care industry, customer observations are a focal point of service quality. To
improve quality, service marketers have to identify the expectation of targetted customers. Pediatric
dentistry is well positioned to help ameliorate the Early Childhood Caries (ECC) disease burden. As
stated in the Surgeon General’s 2000 report, ECC is the most common chronic childhood disease, with a
prevalence five times that of asthma. The key to prevention is early intervention and regular preventive
dental care based on risk and disease management. In disease management, if perceived service exceeds
expected service, the customers are apt to use the service provider again.
Purpose: This study aims to identify factors that affect customers’ service expectations using the
SERVQUAL
model.
Method: The sample was selected using accidental sampling. Service expectations were measured using
the
five SERVQUAL dimensions questionnaire. A total of 93 participants completed the
questionnaire.
Results: The highest customers’ service expectations from five SERVQUAL dimensions was reliability
(3.97). The relationship of reliability service quality with education level of customers was 2.039 times that
of others service quality (OR = 2.039, CI = 0.429 to 9.686). The relationship of reliability service quality
with customer has visited other health cares was 2.141 times that of others service quality (OR = 2.141, CI
= 00.451 to 10.178).
Conclusion: To make the customers to use the services and improve the quality of service in the
department of pediatric dentistry in Airlangga dental hospital, reliability must be provided based on
customers’ service expectations.

Keywords: Service Quality; Customers’ Expectations; Dental

Hospital.
Introduction Universitas Airlangga Surabaya 60115, Indonesia
Email: [email protected]
In the 21st century, all successful organizations adopt
customer focus as the central pillar of their strategic
planning1. Top service companies recognize that
outstanding quality gives them a potent competitive
advantage that leads to superior sales and profit
performance2.

Corresponding Author:
Firdauzi Rimadhan
Department of Administration and Health Policy,
Faculty of Public Health, Airlangga University,
Indonesia Jl. Mulyorejo Kampus C
A service is any activity or benefit that one party can
offer to another which is essentially intangible and does
not result in the ownership of anything2. To evaluate
a service is more complex than to evaluate a product.
To evaluate a product is tangible and its defects can
be detected, its functioning assessed and its durability
compared. To evaluate a service, it is first purchased and
then produced and consumed simultaneously, then the
possible nonconformities are produced and experienced,
characterizing their inseparability3.

Similar to other service industries, health care

has become a highly competitive and rapidly growing
industry worldwide1. In the health care industry,
customer observations are a focal point of service
471 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 471

quality. To improve quality, service marketers have to 5. Empathy: caring and individualized attention
identify the key determinants of service quality (that is, that the firm provides to its customers
the key criteria customers use to judge quality), what
target customers’ expectations are, and how customers This study aims to identify factors that affect
rate the firm’s service in relation to these criterias customers’ service expectations in the department of
against what they expected2. pediatric dentistry in Airlangga dental hospital using
the SERVQUAL model. To make the customers use
Airlangga Dental Hospital is the first sophisticated the service provider, most hospitals should improve the
hospital in Indonesia and serves patients from all parts quality of their services.
of eastern Indonesia. Airlangga dental hospital is
required to provide high quality services with adequate Materials and Method
facilities. One of the facilities in Airlangga dental
hospital is the department of pediatric dentistry. The data was collected in February, 2013. Sampling
was done by non-probability sampling with accidental
Pediatric dentistry is well positioned to help sampling. Samples were taken accidentally, if there have
ameliorate the Early Childhood Caries (ECC) disease been found visitors who minimum three visits to the the
burden. As stated in the Surgeon General’s 2000 report, department of pediatric dentistry in Airlangga dental
ECC is the most common chronic childhood disease, hospital Surabaya, then they will become participants.
with a prevalence five times that of asthma. And ECC The participants were asked to participate in a study
is an entirely preventable disease. The key to prevention that measured service expectations towards Pediatric
is early intervention and regular preventive dental dentistry of dental hospital Surabaya and they were
care based on risk and disease management, but many given the expectations of the SERVQUAL
families only seek dental care when problems occur4. questionnaire. The study instrument was based on
statements measuring five SERVQUAL dimensions.
Grönroos (1984), defined service quality as These dimensions included tangibles (4 items),
matching the expected service towards the perceived reliability (3 items), responsiveness (3 items), assurance
service5. Parasuraman et al. (1988), defined service (4 items), and empathy (3 items). All statements were
quality (SERVQUAL) as the difference between measured on a 4-point Likert scale from 1 for “strongly
consumers’ perceptions and expectations along the 5 disagree” to 4 for “strongly agree.” A total of 93
dimensions of quality5. Kotler et al. (2005), defined participants completed the questionnaire.
service quality as the result of a comparison of what
they expect with what they experience. Customers’ Results
service expectations are formed from past encounters
and experiences, word-of- mouth and the firm’s Customers’ Demographic Characteristic: According
advertising. If perceived service of a given firm exceeds to the survey results, the specific customers’
expected service, customers are apt to use the service demographic characteristics are shown in Table 1.
provider again2.
Table 1: Result of Demographic Characteristics
Accordingly Parasuraman et al. suggested
SERVQUAL’s five dimensions, which are described as Demographic Characteristics N %
follows6: Gender
1. Tangibles: physical facilities, equipment, and Male 31 33.3
appearance of personnel Female 62 66.7
2. Reliability: ability to perform the promised Age (years)
service dependably and accurately 21-30 6 6.5
31-40 40 43.0
3. Responsiveness: willingness to help customers
41-50 47 50.5
and provide prompt service
Education Level
4. Assurance: knowledge and courtesy of employees School 38 40.9
and their ability to inspire trust and confidence
University 55 59.1
Conted… Table 2: Results of SERVQUAL Dimensions

Has visited other health care SERVQUAL Standard

Mean Rank
Yes Dimensions 37 Deviation
39.8
No Tangibles 3.93 56 0.11 60.2 2
Reliability 3.97 0.08 1
Customers’ Service Expectations of SERVQUAL Responsiveness 3.88 0.16 3
Dimensions: The specific customers’ service
Assurance 3.59 0.23 5
expectations of SERVQUAL dimensions are shown in
Empathy 3.81 0.19 4
Table 2.

Mean Customers’ Service Expectations of SERVQUAL Dimensions According to Customers’ Demographic

Characteristic: The specific result of mean customers’ service expectations of SERVQUAL dimensions according
to customers’ demographic characteristic are shown in table 3.

Table 3: Result of Mean Service Expectations of SERVQUAL Dimensions and Demographic

Characteristics

Demographic Characteristics Mean Service Expectations of SERVQUAL Dimensions

Tangibles Reliability Responsiveness Assurance Empathy
Male 3.90 3.97 3.83 3.63 3.77
Gender
Female 3.94 3.98 3.90 3.58 3.83
21-30 3.90 4.00 3.82 3.54 3.79
Age (years) 31-40 3.97 3.96 3.96 3.62 3.82
41-50 3.75 4.00 3.67 3.75 3.83
School 3.93 3.98 3.87 3.61 3.81
Education Level
University 3.92 3.97 3.89 3.56 3.81
Has visited other Yes 3.90 3.98 3.85 3.61 3.81
health cares No 3.96 3.97 3.92 3.56 3.81

Relationship Customers’ Demographic Characteristic with Customers’ Service Expectations of SERVQUAL

Dimensions: The specific results of relationship customers’ demographic characteristic with customers’ service
expectations of SERVQUAL dimensions are shown in Table 4.

Table 4: Result of Relationship Customers’ Demographic Characteristic with Customers’ Service

Expectations of SERVQUAL Dimensions
Demographic Service Expectations of SERVQUAL
Characteristics
Tangibles Reliability Responsiveness Assurance Empathy
OR 1.979 1.554 2.292 - -
Gender
CI 0.783-5.003 0.325-7.418 0.939-5.596 - -
OR - - - - -
Age (years)
CI - - - - -
Education OR 1.231 2.039 0.747 - -
Level CI 0.498-3.044 0.429-9.686 0.312-1.791 - -
Has visited OR 0.323 2.141 0.429 - -
other health
cares CI 0.115-0.902 0.451-10.178 0.171-1.074 - -
Discussion services correctly at the first visit of patients, providing
the services on promised time, maintaining records
This study aims to identify what target customers’
of clients accurately. Hospitals should improve the
expectations are in the department of pediatric dentistry
reliability of their services to increase patients’ loyalty10.
in Airlangga dental hospital. Based on the results of this
study, the customers’ service expectations from five
SERVQUAL dimensions in the department of pediatric
Conclusions
dentistry in Airlangga dental hospital were ranked as In conclusion, according to the study results, to
follows (high to low): reliability (3.97), tangibles (3.93), make the customers use the services and to improve the
responsiveness (3.88), empathy (3.81) and assurance quality of service in department of pediatric dentistry in
(3.59). Reliability as the most important dimension, Airlangga dental hospital, the department of pediatric
and assurance as the least important dimension. These dentistry in Airlangga dental hospital have to provide
results differ from patients’ expectations of service reliability based on customers’ service expectations.
quality in China which were ranked as follows (high to Reliability refers to dependability and steadiness of
low): assurance, empathy, responsiveness, reliability, service. Thus, the department of pediatric dentistry
economy, and tangibles7. In Eastern Saudi Arabia, the in Airlangga dental hospital can help prevention and
highest and lowest means of patients’ expectations were ameliorate the ECC disease.
related to empathy and responsiveness dimensions 8. In
Iranian, the highest and lowest expectation score was Ethical Approval: Health Research Ethics Committee,
related to the assurance (4.7) and reliability (4.43)9. This Faculty of Dental Medicine, Airlangga University,
is likely due to the differences in political, economic, number 1564/KKEPK.FKG/IX/2012.
and cultural factors between countries and statistical
Conflict of Interest: The authors report no conflict
methods used by the researchers, all of which contribute
of
to differences in the demand for medical services7.
interest.
The highest customers’ service expectation from
Source of Funding: Self
five SERVQUAL dimensions was reliability on female
(3.98), within 21-30 and 41-50 years old (4.00), on
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DOI Number: 10.5958/0976-5506.2019.01840.0

The Nurse’s Work Culture Relationship with the Quality of

Nursing Service Between the Government Hospital and Private
Hospital: Comparative Study in 2018

Dilgu Meri1, Meri Neherta2, Zifriyanthi Minanda Putri2

1
Master Degree of Nursing, 2Nursing Faculty, Nursing Faculty, Andalas University Padang Indonesia

ABSTRACT
Quality nursing care is something that the patient wants and it is promised by the nurse. However, at this
time there are still many complaints of the community, the patient’s family and patients on the quality of
services provided by the nurse. This study aims to see differences in the relationship of work culture with
the quality of nursing service in Muhammad Sani Karimun hospital as a public hospital and Bakti Timah
Karimun hospital as a privat hospital in 2018. Design of this research is Comparative design. Samples were
taken stratified random sampling with total of 60 nurses for Muhammad Sani Karimun hospital and 60
nurses for Bakti Timah hospital. The result of statistical test at Muhammad Sani Karimun hospital shows
there is a relationship of work culture of nurse (p value = 0,006). Likewise in Bakti Timah hospital found
a relationship of work culture nurse (p value = 0,005) with quality service nursing. Furthermore Mann
Whitney test obtained service quality variables (p value = 0.006) has a difference between Muhammad Sani
Karimun hospital and Bakti Timah Karimun hospital. However, for nurse work culture variable (p value
= 0,570) there is no difference. This research is expected to be an input for the related hospitals
so as to
improve the quality of nursing service in particular.

Keywords: Work culture, supervision, quality of nursing service, private hospital, public
hospital
Introduction increase in unplanned absences as well as stress-related
occupational health and safety claims, it is alsowill
Hospital as a health care organization is a part of
decrease the productivity and quality of service(4).
health resources that are needed in supporting the
implementation of health services. One of the health Purpose of his research is to discern relationship
services provided is nursing service. The Institute of and differences of work culture and supervision with the
Medicine defines the quality of nursing care as the quality of nursing service in Muhammad Sani Karimun
extent to which health services are provided to hospital and Bakti Timah Karimun Hospital in 2018.
individuals and communities in improving healthcare
with the latest science(1). Materials and Method

Ordem Dos Enfeimeiros which presents six This research is a kind of quantitative research.
categories to determine the quality of nursing service The method or design used is Comparative. This study
based on nurse perception that are patient’s satisfaction, is a research designed to determine the differences and
health promotion, prevention of complication, welfare effects of different variables in a population.
and self-care, and functional adaptation and organization The populations in this study were all nurses at
of nursing(2). the Muhammad Sani Karimun hospital, it is about 170
people and all nurses in Bakti Timah hospital amount
The inability to inculcate a good work culture
to 129 people. So the total number of population from
will affect the ability to maintain the quality of health both hospitals amounted to 299 people. Sample of the
care and will negatively impact patient satisfaction study in public and private hospitals respectively are
and productivity among staff (3). A poor work culture 60 respondents. Sampling technique in this research
also reduces the involvement of employee and can is
stratified random sampling.
476 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 476

Additional data to complete the data will be Table 2: The Relationship of the nursing work
conducted questionnaires about the work culture of culture with the quality of nursing service in Bakti
nurses and the quality of nursing services. To measure Timah Karimun Hospital
the quality of nursing services, the researchers used the
Nursing Quality of nursing service Total
Quality of Nursing Care questionnaire (2). The p
work Not Good Good n%
researchers modified from several questionnaires to value
culture n % n % n %
describe the nurse’s work culture of Work Of Meaning
Not Good 12 60 8 40 20 100
Inventory (WOMI) by Lee, Attitude Scale Toward 0,005
Good 8 20 32 80 40 100
Nursing Profession (ASNP), Environment Scale Od
The Nursing Word Index (PES Table 2 can be seen that 40 respondents who have
- NWI), Nurse- Nurse Collaboration Behavior Scale . (5)
a good work culture as much as 32 people (80%) with
good nursing service quality and 8 people (20%) with
Research Finding poor quality nursing service. While from 20 respondents
with bad work culture as much as 8 (40%) nurses with
The frequency distribution of nursing service quality good services quality and 12 (60%) with poor service
variable, nurse work culture and supervision as much as quality.
41.7% nurses stated that the quality of nursing service in
Chi-Square test results obtained p value = 0.005
Muhammad Sani Karimun hospital is good and 66.7%
(p <0.05) which means there is a relationship between
of nurses stated the quality of nursing service at Bakti
nurse work culture with the quality of nursing services
Timah Karimun hospital is good.
in Bakti Timah Karimun hospitals.
While for nurse work culture variable is 61,7%
nurse stated that work culture of nurse in Muhammad Table 3: The Differences in Quality of Nursing Cares
between RS.Bakti Timah and Muhammad Sani
Sani Karimun hospital good and equal to 66,7% nurse
Karimun hospital Karimun District
stated nurse work culture at Bakti Timah Karimun
hospital is good. Variables Hospital Status n p value
Muhammad Sani Karimun
Quality of
Table 1: The Relationship of nurse working culture hospital
nursing 60 0,006
with quality of nursing service in Muhammad Sani Bakti Timah Karimun
services
Hospital
Karimun Hospital
Muhammad Sani Karimun
Nursing
Quality of nursing hospital
work 60 0,570
Nursing service Total Bakti Timah Karimun
p culture
work Not n% Hospital
Good value
culture Good
n % n % n % The results of the analysis in Table 3 shows that the
Not Good 19 82,6 4 17,4 23 100 variable quality of nursing care with respondents from
0,006 hospitals M. Sani Karimun numbered 60 nurses and
Good 16 43,2 21 56,8 37 100
the number of respondents from the RS. Bakti Timah
Table 1 can be seen that of 37 respondents who have
Karimun amounted to 60 people got value p value =
good work culture as many as 21 people (56.8%) with
0.006 (<0.05) means there is a difference in quality of
good nursing service quality and 16 people (43.2%) with
nursing service between Muhammad Sani Karimun
poor service quality. While from 23 respondents with
hospital with RS. Bakti Timah Karimun.
bad work culture as much as 4 (17,4%) nurse with good
service quality and 19 (82,6%) with poor service quality. The results of the analysis in Table 5.3 shows
that nurses work culture variable with the number of
Chi-Square test results obtained p value = 0.006 respondents from hospitals M. Sani Karimun numbered
(p <0.05) which means there is a relationship between 60 nurses and the number of respondents from the RS.
nurse work culture with the quality of nursing service. Bakti Timah Karimun amounted to 60 people got p
value
= 0,570 (> 0,05) means there is no difference of work Lack of nurse knowledge about the policy in
culture of nurses between Muhammad Sani Karimun Muhammad Sani Karimun hospital about the
hospital with RS. Bakti Timah Karimun. quality of nursing service is one of the items of
the organization of health services.
Discussion Based on Law No. 69 of 2014 on hospital
A. Picture of Quality of Nursing Service at obligations in Indonesia which are obliged to
Muhammad Sani Karimun and Bakti Timah provide safe, quality discrimination and effective
Karimun hospital. health services by prioritizing the interests of
patients in accordance with hospital service
The results of the research showed the quality
standards. In addition, the hospital is also obliged
of nursing service in RSUD M. SaniKarimun to formulate a policy conducive to health services
in
in accordance with the code of ethics Hospital
2018 that is equal to 41.7% nurses stated good.
While the results of research in Bakti Timah Based on the analysis of questionnaires at Bakti
Karimun hospital Karimun showed that the Timah Karimun Hospital it was found that less
quality of nursing services in hospitals. Bakti than half the nurses stated the nurse’s ability
Timah Karimun in 2018 that is equal to 66.7% to improve the patient and family’s ability to
nurses stated good. provide ready-made therapy for patients who
were part of functional adaptation. In functional
Davis defines quality as a dynamic condition adaptation there are several items used to measure
that deals with products, services, people, the continuity of the process of providing nursing
processes, and environments that meet or exceed services, maximizing the use of resources of the
expectations. Research conducted in Muhammad patient’s family and optimizing the increased
Sani Karimun hospital 19 statements about the capacity of patient and family knowledge of the
disseminated through questionnaires on the patient to manage self-care .
quality of nursing services found that all nurses
(100%) stated not knowing the hospital policy B. Work Culture and Its Relation to Quality of
about minimum service standards to improve the Nursing Service at Muhammad Sani Karimun
quality of service. Furthermore, more than half and Bakti Timah Karimun hospital.
(98.3%) of nurses said they were unable to handle The result of research on the correlation between
a situation that was less conducive for patients the working culture and the quality of nursing
who could help improve patients’ welfare and service in Muhammad Sani Karimun hospital
daily activities. illustrates that a good work culture has more
proportion for the improvement of good nursing
The research conducted in Bakti Timah Karimun
service quality by 21 people (56,8%) and 16
hospital Karimun where 19 statements about
people (43,2 %) results in poor service quality.
the quality of nursing service based on the
Statistical test results can be seen that there is a
questionnaire distributed found that as many
significant relationship (p value = 0.006) between
as
the work culture of nurses with the quality of
28.3% nurses said did not improve the ability
nursing service
of patients and invite family members closest
to provide therapy that has been prepared for The results of the research in Bakti Timah
patients. Similarly, as many as 21.7% of nurses Karimun hospital. Results concerning the
said they did not evaluate interventions that help relationship of work culture with the quality of
improve patient health and daily activities. nursing service in Bakti Timah Karimun hospital
illustrates that a good work culture has more
Based on the analysis of questionnaires in proportion to improve the quality of good
Muhammad Sani Karimun hospital can be seen nursing service as much as
that all nurses as samples in the study did not 32 people (82%) and as many as 8 people (20%)
know the hospital policy about hospital minimum produce poor service quality. Statistical test results
service standards caused by lack of socialization can be seen that there is a significant relationship
from management related to hospital policy. (p
value = 0.005) between the work culture of nurses These differences shows that private hospitals play
with the quality of nursing service. a significant role in society, and higher perceived
The results of this study are in accordance with service quality will only increase demand for their
the concepts put forward (6) where poor culture services (9).
generally manifests as disruptive behavior, The result of bivariate data of difference shows
factionalism, or the emergence of counter-culture, that mean value of Bakti Timah Karimun hospital
actively working against the best interests of the is bigger than Muhammad Sani Karimun hospital.
organization as a whole. A poor work culture The statistic shows that there is a difference of
also erodes employee engagement and may lead
the quality of nursing service of Muhammad
to an increase in unplanned absenteeism and
Sani Karimun hospital and Bakti Timah Karimun
occupational health and safety claims related to
hospital is caused by the ineffective nurse in
stress. It can not be denied, the productivity and
giving nursing care which we can see in the
quality of services will decrease.
distribution of questionnaire answers where
The results of the questionnaire analysis found as many as
that the lack of cooperation among staff, inflexible 66,7% nurses stated no intervention to prevent
work schedules and the lack of caring nurses is complication because nurses are more waiting
part of the attitude and behavior of nurses when for therapy from doctors so as to prevent more
working as well as the factors causing the nurse’s complications delegated to medical personnel
work culture is not good so the quality of nursing such as doctors.
service becomes less good. Humans show a
variety of attitudes toward work. Attitude is the D. Differences of nurse working culture between
tendency of the soul to something. This tendency RS. Bakti Tin with RSUD M.
ranges from taking full acceptance or refusing to SaniKarimunKab. Karimun2018.
the utmost. Zulkifli (2014) states that attitudes The results of the analysis in Table 5.3 shows that
toward work can also be interpreted as a joy of
nurses work culture variable with the number
work compared to other activities or simply
of respondents from hospitals Muhammad Sani
to gain satisfaction from his own work or feel
Karimun numbered 60 nurses and the number
compelled to do something just for his life (7) .
of respondents from the Bakti Timah Karimun
However, if nurses are not satisfied with their hospital amounted to 60 people got p value =
work and who have less good attitude toward 0,570 (> 0,05) means there is no difference of
their profession will experience more problems work culture of nurses between Muhammad Sani
such as stress, tension, and high anxiety. This Karimun hospital with RS. Bakti Timah Karimun.
will deter them in their work. Nurses’ attitudes
toward their work, profession, organization, and Based on the questionnaire analysis can be seen
administration will predict the behavior they will many similarities between Muhammad Sani
show in it (8). Karimun hospital and Bakti Timah Karimun
hospital Karimun. The same thing is seen between
C. Differences in quality of nursing care between
Muhammad Sani Karimun hospital and Bakti
hospitals. Bakti Tin with Muhammad Sani
Timah Karimun hospital, where 71% of nurses
Karimun hospital Kab. Karimun 2018.
stated that they have an inflexible work schedule.
The results of the analysis in Table 5.3 shows Many people work long hours, consequently they
that the variable quality of nursing care with face conflict between family and work. Especially
respondents from M. Sani Karimun hospitals for women, do not have the time they want for
numbered 60 nurses and the number of the family because of working hours long and
respondents from the RS. Bakti Timah uncomfortable (10).
Karimun amounted to
60 people got value p value = 0.006 (<0.05) Working in flexible working hours allows people
means there is a difference in quality of nursing to manage their daily lives better and reduce
service between Muhammad Sani Karimun family conflicts. Results of research conducted
hospital with Bakti Timah Karimun hospital. by (10) showed that the flexibility of work has
a
positive and significant effect on job satisfaction, REFERENCES
work flexibility has a positive and significant
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service as an effort to improve the quality of nursing to
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This research will produce an overview of the Workplace Culture Improvements: A Review of
application of nurse work culture, supervision on the the Literature. 2014;(June):1–93.
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Of Leadership Styles In Creating Quality Work
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Karimun hospital there is difference nurse work culture
between two hospitals. The next researchers next could 7. Djumlani A. Hubungan Budaya Kerja Dengan
dig factor others that affect quality service nursing and Komitmen Sakit Jiwa Daerah Atma Husada
factor cause existence difference quality service nursing Mahakam. 2014;2(2):1316–27.
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Sources of Funding: This study was conducted using a Thailand. 2013;4(11):176–84.
source of funds derived from the researcher himself
10. Surakarta UM, Nuraini D. Pengaruh fleksibilitas
Ethical Clearance: This study has passed of the kerja dan spesialisasi pekerjaan terhadap kinerja
medical reseach ethics of the Dr. M. Djamil Hospital karyawan dengan kepuasan kerja sebagai variabel
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DOI Number: 10.5958/0976-5506.2019.01616.4

Relationship of Hand-Hygiene Compliance Score with Nurse’s

Engagement in Intensive Care Unit

Boy Sandy Sunardhi1, Prima Nerito1, Tito Yustiawan2

1
Post Graduate Student, 2Lecturer, Departement of Administration and Public
Policy, Airlangga University, Surabaya

ABSTRACT
Background: Infectious diseases are still the main cause of the high rate of morbidity and mortality in
the world. Hand-hygiene behavior is one factor that has a major influence on prevention of nosocomial
infections (INOS) in the hospital.
Objective: the aim of this research is to find the correlation of nurse engagement with the level of
compliance
of hand-hygiene ICU nurse activity in Surabaya Islamic Hospital.
Method: This research is a quantitative analytic research and use descriptive design with cross sectional
research method. The sampling technique used in this research is total sampling technique that is taking
data of all nurses who are in ICU.
Result: The results of this study indicate that nurse engagement has a correlation with the compliance of
nurses in implementing hand-hygiene.
Keywords: Compliance, Engagement, Hand-Hygiene, Nurse
Introduction these infections are also impacted on the quality of
health services and on increased healthcare financing 3.
Act Number 44 year of 2009 on Hospital states
According to WHO (2011) HAIs are the patient-
that hospitals must apply the patient safety standards 1.
acquired infections during treatment procedures and
Patient Safety Program is to ensure patient safety in the
medical procedures in health services that occurred after
hospital through prevention of errors in the delivery of
≥48 hours of treatment and ≤30 days after released from
health services. Hospitals are required to provide quality
health facility. Based on the French National Prevalence
and transparent health services to the public, especially
Survey, the frequent locations of nosocomial infections
for assurance of patient safety, so hospitals need to
include urinary tract, airway, surgical wound, skin and
improve the services quality, especially in the prevention
tissue, ears, nose and throat, eyes, locations of catheter
and control of infections2.
put in and other locations4.
The prevention and control of infections is become
According to the data from Indonesian Ministry of
particular concern due to the incidence of infections in
Health, nosocomial infections rates which occurring
hospitals are considered as a serious problem because
in some countries of European and American are low,
they threaten the health and safety of patients and
approximately 1% if it is compared with the incidence
health workers globally. In addition, the incidence
in the countries of Asia, Latin America and Sub-Saharan
of
Africa which are high, reaching more than 40%, and
according to the data of WHO (2009), the incidence rate
Corresponding Author: of infection in the hospital are about 3-21% (mean
Boy Sandy Sunardhi of
Departement of Administration and Public Policy, 9%). By seeing these data, the hospital should anticipate
Airlangga University, Surabaya to prevent nosocomial infections incidences in the
Street of Dr. Ir. H. Soekarno, Mulyorejo, 60115 future. One of the efforts is through the application of
Email: [email protected] hand-hygiene 5-moments that are before contact
with
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 481

patients, before administer aseptic action, after exposure Results and Discussion
of patient’s body fluid, after contact with patient, after
Based on surveys given to nurses using Gallup
contact with the environment around patient.
Survey to measure nurse’s engagement and secondary
Data of hand-hygiene compliance score of nurses at data of Committee on Infection Prevention and Control
ICU in August 2017 was 80% and in September 2017 of Surabaya Islamic Hospital, then the following data
was 80%. These are still lower than the standards set are obtained.
by the hospital that is 85%. There are many factors that Table 1: Frequency Distribution of Respondents
influence nurse compliance in applying hand-hygiene Based on Nurse’s Engagement at ICU Room of
5-moments, one of them is nurse’s engagement to Surabaya Islamic Hospital in 2017
the
organization5. Frequency Percentage
Engagement
(n) (%)
To evaluate the relationship of nurse’s engagement Not engaged 5 41.7
with nurse’s compliance of hand-hygiene at ICU of
Engaged 7 58.3
RSIS, it is conducted the scientific approach in order to
Total 12 100.0
find the relationship between variables so that the nurse’s
engagement at ICU of RSIS can be measured through the Source: Primary Data, 2017
implementation of hand-hygiene 5-moments. The results Based on Table 1 it can be learned that most of the
obtained will be useful for RSIS management in planning implementer nurses (58.3%) at ICU Room of Surabaya
the best strategies for improving or maintaining excellent Islamic Hospital include engaged employees.
performance through improvement or enhancement
Table 2: Frequency Distribution of Respondents
of appropriate infection prevention and control. It is
Based on Nurse’s Compliance in Implementing
necessary to develop a performance-based nursing policy
Hand-Hygiene at ICU Room of Surabaya Islam
so as it can improve the nurse’s performance in
Hospital in 2017
Infectious Diseases Prevention against the prevention of
nosocomial infections at RSIS. As a result, the number of Hand-Hygiene Frequency Percentage
nosocomial infections can be decreasing so that RSIS can Compliance (n) (%)
provide the best service for the patient. This study is aims Non comply 7 41.7%
to analyze the relationship between nurse’s engagements Comply 5 58.3%
with hand- hygiene compliance at ICU of RSIS. Total 12 100.0
Source: Primary Data, 2017
Method Based on Table 2 it can be learned that from 12
This study is a quantitative analytic research and implementer nurses, most of the nurses at ICU of
using descriptive design with cross-sectional method of Surabaya Islamic Hospital are non-comply to
research. Cross-sectional method of research is one form implementing hand- hygiene, those are 7 peoples
of the most frequently observational (non-experimental) (58.3%).
study. In a broader meaning, the cross-sectional Table 3: Relationship of Nurse’s Engagement with
study includes all types of research whose variable Nurse’s Compliance in Implementing Hand-
measurements were performed only once at one Hygiene at ICU Room of Surabaya Islamic Hospital
time in 2017
6
. This study is to determine the correlation of nurse’s
engagement with hand-hygiene behavior by means Hand-Hygiene
Compliance Total
observation approach or data collection, which the data
Engagement

was taken in the form of questionnaire to measure Non-comply Comply

nurse’s engagement by using Gallup Survey. The n % N % N %
research was conducted at Surabaya Islamic Hospital
Not engaged 5 100.0 0 0.0 5 100.0
with the time research was conducted from December 20
Engaged 2 28.5 5 71.4 7 100.0
until December 27, 2017. The number of respondents
Total 7 58.3 5 41.6 12 100.0
used as many as 12 nurses of ICU who the total
sampling. Source: Primary Data, 2017
482 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
According to Table 3, it can be learned that the Employees’ engagement is essential in improving
more not engaged of implementer nurses at ICU of employees’ initiatives to implementing hand-hygiene
Islamic Hospital Surabaya, the higher the tendency of 5-moments. When it is compared to forcing employees
the nurse to non-comply in implementing hand- through regulations, by improving engagement is proved
hygiene at ICU of Surabaya Islamic Hospital. The more successful in increasing employees’ compliance
results of cross- tabulation in this study indicate that score in hand-hygiene10. This was support the results
nurse’s engagement are tends to have relationship with of Table 3, where the more nurses are not engaged, the
the nurse’s compliance in implementing hand-hygiene. more nurses are non-comply in hand-hygiene.

Discussion Conclusions and Suggestions

Based on the observation at ICU of Surabaya The results of this study indicate that nurse’s
Islamic Hospital by using observation sheets and check engagement tends to have relationship with nurse’s
list, the implementation of hand-hygiene 5-moments has compliance in implementing hand-hygiene.
not implemented well that is 80% while the standard
set by the hospital is 85%. This is in line with a study Lack of compliance in hand-hygiene of nurse at ICU
of 40 hospitals that reported health worker compliance is more due to lack of supervisors. To increasing hand-
to hand-hygiene before and after contact to patient are hygiene scores at ICU it can be started by modeling
vary between 24% to 89% (mean of 56.6%). The study with pear group method. From this pear group then
was conducted after the promotion of WHO program in they can remind each other to implement hand-hygiene
infection control7. 5-moments well.
From hand-hygiene 5-moments, these are before Giving non-monetary rewards can also be done to
contact with patient, after contact with patient, before improve nurse’s engagement. Giving rewards to the best
aseptic action, after exposure of patient’s body fluid, employees in this month, giving bonus for achieving the
after contact with patient, after contact with area around target can be one of steps that can be done.
patient, then the most often missed is the moment before
contact with patient. This is in line with previous study Ethical Clearance: Taken from ethic committee of the
that calculated the value of compliance at the momen 1 hospital
is the lowest point by 0% before conducting the training
and it was increased to 25% after conducting Source of Funding: Self Funding
training
8
Conflict of Interest: There aren’t any relevant
. However, contrasting with that study, ICU nurses are conflict
had accepted regular training on hand-hygiene so that of interest
unreached target of hand-hygiene is not due to low level
of education.
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6. Sastroasmoro S, Ismael S. Dasar-Dasar 12. Dwi Bagus Susilo, KEPATUHAN

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Barat; Yogyakarta. 2014 16. Kadek Herna, Hubungan Tingkat Pengetahuan
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DOI Number: 10.5958/0976-5506.2019.01617.6

Development of Management Skills Head of Public Health

Center Based on Analysis of Management Skills Theory of
Cameron and Quinn

Martha Wahani Patrianty1, Nyoman Anita Damayanti2, Tito Yustiawan2

1
Student, Master Program Study Program Administration and Health Policy, 2Departments of
Administration and Health Policy, Faculty of Public Health, Airlangga University

ABSTRACT
Head of Puskesmas as manajer, is required to have managerial skill. This study to assess management
skills Head of Puskesmas then develop recommendations based on the description of the results of the
assessment. The type of descriptive research, sampling technique total sampling, data retrieval techniques
obtained from the instrument that has been filled by the boss, peers, subordinates and yourself. Data
analysis techniques using Cameron and Quinn›s Management Skills Assessment Instrument (MSAI). The
variables studied are the type of culture in organization and management skill in each organizational culture
as sub variable. Used Likert type as a questionnaire scale. Using the total population as respondents.
Results from the assessment of superiors, peers, subordinates, show that the culture of adhocracy is more
dominant. The next sequence is the clan culture and then the hierarchy culture and market culture. The
implementation of management skills is very strong. In sequence, the strength of managing innovation is at
the top, followed by energizing employees, managing team, control system, coordination, interpersonal
relationship, continuous improvement, managing the future, managing customer service, the development
of others, acculturation and competitiveness. As a recommendation, efforts were made to develop
management skills in 12 managerial competencies, with a primary focus on the development of lower-level
managerial competencies.

Keywords: Management Skills, Assessment, Instrument

Introduction The purpose of this study to assess the management
skills of Public Health Center Head and make
Head of Public Health Center is a manager. To
recommendations on the development of management
place a person as Head of Public Health Center, it takes
skills of Public Health Center Heads in Karangketug
lot of consideration. It is necessary a Head of Public
Public Health Center.
Health Center as a manager who can bring Public Health
Center to be the means to achieve the goal as well as Culture is a shared perception shared by all
possible. Head of Public Health Center was appointed by members of the organization.1 Organizational culture
Pasuruan City Government based on proposal from emerges as a shared assumption held by an
Pasuruan City Health Office. In the proposed names was organization, as well as a differentiator or a special
appointed as head of the Public Health Center, Health feature for the existence of an organization. Cameron
Office do not make spesific assessment of the and Quinn formulate the types of culture within the
management skills of each candidate. organization called The Competing Value Framework.2
Futhermore, Cameron and Quinn develop two
Corresponding Author: quantitative survey instruments called with the
Martha Wahani Patrianty Organizational Culture Assessment Instrument (OCAI)
Student, Master Program Study Program and the Management Skills Assessment Instrument
Administration and Health Policy, (MSAI). Within the OCAI, identified employee
Faculty of Public Health, Airlangga University perceptions and aspirations about the current and
Phone: + 6282231858210 desired organizational culture, which can be categorized
Emai: [email protected] into the following four types:
485 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 485

1. Clan Culture: The main task of management is 2. Calculate the value of each questionnaire item by :
to control and nurture employees to make it easier
for them to participate. The total weight of the respondent's
answer
2. Adhocracy Culture: The main task of Ni =
Number of Respondents
management is to support and encourage the Information : Ni = value per item
creation of entrepreneurial spirit and creativity.
The weight for each respondent’s answer is as
3. Market Culture: The main task of management follows :
is to control the organization to achieve Strongly Agree :5
productivity, results and objectives and benefits. Agree :4
4. Hierarchy Culture: The main task of Enough :3
management is to produce goods and services Less Agree :2
efficiently so as to achieve prosperity in the Disagree :1
company. 3. Calculate the average value of five items
Management Skills Assessment Instrumen are tools representing each managerial skill
an assessment that helps managers identify the strengths 4. Plot the average value of each managerial skill to
and weaknesses of organizations realize their desired the MSAI diagram
culture.2 In this article used the MSAI method because
5. The higher the average value indicates that the
there is more division of management skills criteria
managerial skills are stronger by following the rules:
which will be combined with OCAI as a complement
of management skills analysis for the development of a. 1,00-1,80 (very weak)
managerial capabilities Head of Public Health Center at b. >1,80-2,60 (weak)
Karangketug Public Health Center. c. >2,60-3,40 (enough)
d. >3,40-4,20 (strong)
Methode Analisis
e. >4,20-5,00 (very strong)
Types of research: The type of research used is a 6. Comparing the results of judgment in self with
descriptive method that aims to collect facts, describe,
others (superiors, peers, subordinates)
analyze and interpret data into a clear and precise
information. The information obtained is a systematic Results Analysis
and factual review of management skills Head of Public
Health Center at Karangketug Public Health Center. Table 1: Results of Managerial Skill From
Superiors, Peers, Subordinates and Self Assessment
Sampling Technique: The sampling technique used in
this study is total sampling. This means that the entire Managerial Value Average
Culture Item
population in the Karangketug Public Health Center will Skill Others Self Others Self
be taken as respondents. 12 4,67 4
Managing

18 4,70 5
Team

Data Retrieval Techniques: Data taken from the 21 4,60 5 4,630 4,6
instrument that has been filled by the boss (Head of 22 4,63 4
Health Office, Secretary of Health Service, Head of 49 4,55 5
Field), peers (Head of Others Public Health Center in 1 4,82 5
Development Interpersonal
Relationship

Pasuruan City), subordinate (employee of Karangketug 13 4,65 5

Managing

Public Health Center), and self (Head of Karangketug 23 4,48 4 4,598 4,8
Public Health Center) 48 4,51 5
Data Analysis Technique: Data analysis technique used 50 4,53 5
is descriptive analysis which started with calculation 5 4,55 4
Managing

using Management Skill Assessment Instrument (MSAI) 20 4,56 5

Others

24 4,58 5 4,584 4,8

The

which formulated by Cameron and Quinn that is :

25 4,60 5
1. Grouping the questionnaire items follows the 47 4,63 5
variable operational table above.
Conted… the lowest rating. While from the assessment itself, Head
2 4,75 5 of Public Health Center is very capable of performing
8 4,62 5 managing continuous improvement, energizing

Innovation
Managing 26 4,67 5 4,644 4,6 employees, managing acculturation and managing
51 4,62 5 coordination. While the ability to compete relatively less
59 4,56 3 than optimal.
14 4,74 5
Mapping and Managerial Skill Analysis Based on
27 4,63 5
Managing Managing The

28 4,51 5 4,586 4,6 Cameron and Quinn Theory

Future

45 4,60 5
46 4,45 3
9 4,74 5
Improvement

29 4,62 5
Continous

44 4,53 5 4,590 5
52 4,58 5
53 4,48 5
7 4,25 2
15 4,60 5
Competitiveness

30 4,53 5
Managing

4,482 4
42 4,48 3
43 4,55 5
Figure 1: Managerial Skill Mapping from Assessing
3 4,77 5
Superiors, Peer Associates, Subordinates
6 4,72 5
Employees
Energizing

31 4,53 5 4,640 5 Information: Value for MA (Managing

32 4,53 5 Acculturation)
60 4,65 5 of 4,57241, MTCS (Managing The Control System)
33 4,51 3 of
Managing
Customer

35 4,67 5 4,64828, MC (Managing Coordination) of 4,60345, MC

Focus

41 4,65 5 4,586 4,6 (Managing Competitiveness) of 4,60345, EE

54 4,50 5 (Energizing Employees) of 4,55517, MCS (Managing
55 4,60 5 Customer Service) of 4,56207, MT (Managing Teams)
10 4,70 5 of 4,63448, MIR (Managing Interpersonal Relationship)
11 4,50 5
Hierarchy

Control System Acculturation

of 4,60345, MTDOO (Managing The Development of

Managing

34 4,62 5 4,568 5 Others) of

40 4,53 5 4,58966, MI (Managing Innovation) of 4,68276, MTF
56 4,41 5
(Managing The Future) of 4,58966, MCI (Managing
4 4,70 3
Continous Improvement) of 4,55862.
6 4,72 5
Managing

36 4,60 5 4,626 4,6

39 4,56 5
Coordination

57 4,55 5
17 4,70 5
19 4,62 5
Managing

37 4,55 5 4,612 5
38 4,63 5
58 4,56 5
From table 1 it shows that superiors, peers,
subordinates assess that the ability to innovate is the
most powerfull ability, while the ability to compete get
Information: Value for hierarchy culture of 4,608,
market culture of 4,574, clan culture of 4,609, adhocracy
culture of 4,610.
From the mapping above shows that the culture streghts and weaknesses. Managers use the feedback
which is dominant is adhocracy followed by clan data in the report is to identify the competencies that
culture, hierarchy, market. Karangketug Public Health require improvement and competency where changes
Center has put forward innovation and initiative and also could facilitate the desired cultural shift.
apply family culture in operation of work team culture
and needed development in the field of structuring and To improve skills generate employee’s energy, Head
increasing competition and increasing income. of Public Health Center need to learn to motivative
employees. Motivating employees can be through the
provision of incentives, rewards, appreciate what the
employee has done.3 The commitment and the support
from the leader is ways to appreciate the contribution,
loyalty, dedication and effort of the employees.
Motivation to gain training and development
opportunities affect employee performance.3 Managers
need to provide working environment, working
conditions, interpersonal relationships, organizational
policies that are conducive to improving employee
performance.4

To improve the acculturation capability the Head of

Figure 2: Managerial Skill Mapping from Public Health Center needs to use organizational culture
Self Assessment as a control management mechanism and to install a
trust system among employees.5
Information: Value for MA of 5, MTCS of 4,6, MC of
5, MC of 5, EE of 4, MCS of 4,6, MT of 4,6, MIR of The Head of the Public Health Center needs to
4,8, MTDOO of 4,8, MI of 5, MTF of 4,6, MCI of 4,6. ensure that activities are in line with the plan, objectives
are achieved, human and financial resources and material
resources are used effectively and efficiently. Therefore
the Head of Public Health Center needs to improve
her control management. A good management control
system should generate motivation for employees.6

Head of Public Health Center need to make

various innovations for customer. The innovation is
a follow up in the competition of health care services.
Information: Value for hierarchy culture of 4,86, Customer Relationship Management (CRM) includes
market culture of 4,53, clan culture of 4,73, adhocracy the methods and technologies companies use to manage
culture of 4,73. their relationships with customers.7 The information
stored for each customer and prospect analyzed and
From the above mapping shows that the culture
used for personalized automatically based on customer
which is dominant is hierarchy then followed by the
information stored in the system. Rational Unified
culture of adhocracy then clan terminated market.
Process (RUP) is a software development approach
There is a clear distinction. Her associates assess that is done repeatedly, focus on the architecture, more
the manajer as the weakest in quadrant where managers directed based on use case (use case driven). The
8

assess themselves performing quite effectively. The purpose of making use cases is to communicate what
might suggest areas for targeted self-improvement. Most is required from the user’s perspective. Users who have
managers judge themselves higher than they are rated CCM positions use a management system to perform
by their peers. At present, the assessment is sufficient to a reminder that is in the system. Users who have
help managers gain an overall picture of her managerial administrative positions CCM use management system
to follow up customer after done reminder.
Need to improve managerial skill in managing continue to improve its effectiveness, should be included
interpersonal relationships. Management can play a role in the quality policy. Also the management review to be
in promoting friendship and a climate of openness in the done at planned intervals should include assessments of
workplace, initiate social activities, build a sustainable opportunities for improvement and the need for changes
team, involving employees in the recruitment process, to the quality of the management system including
interact with members on a regular basis, talking to quality policy and quality objectives.
everyone, not shouting at one of the employees in
public, talking to a team member directly, sit down with The Head of Public Health Center need to improve
the team and help them plan their day.9 Manager must the coordination management skill. The success of
be accessible to a team member, direct intervention organizational activities depens on the division of labor,
in cases of conflict between subordinates, sitting how the work will be designed, how the delegation
with the individual, present in informal meeting with of authority works, every member of the organization
subordinates, present for picnic, delegate responsibilities must be clear who does what, divided tasks are certainly
and ask them to take individual responsibility, rewarding running toward the goals of the organization.14 Organize
employees who perform well, not arrogant, not hurt the work, coordinate the entire process by dividing it into
team members. smaller operations, through work instructions, schedules,
specification procedures.
Head of Public Health Center need to improve the
future management skills. The development of visionary The Head of Public Health Center need to improve
leadership by motivating employees to produce the self managing team skill. The role of a leader is
innovative work, learning to understand about politics, crucial to the organization’s progress when it comes to
sociology and general managerial techniques, difficult providing support for the team’s success.15 The leader
learning, maximize energy to issue quality decisions, must be to build relationships and political awareness
thinking and simple logic, dare to take risks.10 among members of the team or organization, guide
information and keep up with activities by monitoring
The Head of Public Health Center need to improve both inside and outside the team, invites team members
the skill of managing innovation. When innovation is or organization to always attend a meeting of the
not perceived by the organization as a challenge, there organization, empowering team.
will be no innovation.11 Innovation should be part of
agency activities, must be interesting and useful, the Conclusion
best way to preserve and perpetuate the organization.
The importance of the need for innovation and the time (a) The implementation of managerial skill for all
frame must be defined and elaborated. There needs to be cultures into the category is very strong.
an innovation plan, with a specific purpose. (b) Application of hierarchy culture managerial skill
need to be limited because it will hamper the
The Head of Public Health Center need to improve
optimization of the application of market and
the skill of managing the competition. Management
adhocracy culture.
is actively taking advantage of opportunities and
strategically controlling the effectiveness and Suggestion: It takes an increasing application of market
effectiveness of its activities, observing new trends culture in order to increase competition and increase
and will occur in the future, observe and evaluate the revenue.
economic trends, maximize information technology to
strengthen the effectiveness and efficiency of marketing Ethical Approval: Related departments should be
and services, improve employee productivity.12 assured about the confidentiality of the results of
questionnaires.
The Head of Public Health Center need to
improve skill of continuous improvement. Continuous Conflict of Interest: The authors report no conflict
improvement requires management support,13 provide of
evidence of its commitment to the development and interest.
implementation of the quality management system Source of Funding: Self
and
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DOI Number: 10.5958/0976-5506.2019.01618.8

Assessment of the Anatomical Causes of Persistent Nasal

Obstruction after Primary Septorhinoplasty

Salim Hussain Ibrahim

Assist. Prof. Otorhinolaryngology, Head and Neck Surgery, Department of Surgery, Tikrit
Medical
College, Tikrit University, Salah Aldin, Iraq

ABSTRACT
Background: Septorhinoplasty is an operation for improving the appearance of the nose and nasal
breathing,
but persistent nasal obstruction may occurs and may require revision surgery.
Objectives: To determine the incidence and significance of persistent nasal obstruction after
septorhinoplasty with different external nasal deformities. To recognize the anatomical structures that
cause persistent nasal obstruction and their surgical correction.
Patients and Method: A prospective case study of 39 patients who have persistent nasal obstruction from
a total 230 patients who underwent closed septorhinoplasty at Tikrit Teaching Hospital and Private practice
between January 2014 and June 2017. The nasal obstruction was subjectively graded by using Nasal
Obstruction System Evaluation (NOSE)scale.
Results: Persistent nasal obstruction was found in (17%) after a minimum one year post operatively. It was
common in patients with deviated nose (20.6%). The nasal septal deviation was the common anatomical
cause (69.2%),surgical interference was indicated in (66.7%), and revision septoplasty was the common
surgical procedure used (66.4%).
Conclusion: There was no statistically significant association between external nasal deviation with
occurrence and severity of nasal obstruction,and between severity of nasal obstruction and type of
external nasal deviation after septorhinoplasty. The surgical planning for septorhinoplasty must be taken
in consideration the improving nasal air way, as well cosmetic outcome, to avoid revision surgery that are
challenging operation with risk of septal perforation.

Keywords: Deviated nose, Nasal obstruction,

Septorhinoplasty.
Introduction some patients who have had septoplasty or
rhinoplasty
Septorhinoplasty is a cosmetic nasal surgery 2,3
.Despite the cause of the persistent nasal obstruction
done to improve the appearance of the nose and nasal commonly multifactorial 4, the inadequate correction of
breathing. The correction of nasal septum plays a vital the deformities would be the main cause7. The reduction
role in straighten the deviated nose and improve nasal rhinoplasty decreases the cross-sectional area of the
respiration1. , Nasal obstruction may be persistent in nasal valve by 25% and the piriform aperture by
13%
2
.This is due to hump removal,lateral osteotomy and
Corresponding Author: over resection of the lower or upper lateral cartilage
Dr. Salim Hussain Ibrahim that resulting in nasal valve collapse, So that septoplasty
Assist. Prof. Otorhinolaryngology, indicated even for simple asymptomatic septal deviation.
Head and Neck Surgery, Department of Surgery,
Tikrit Medical College, Tikrit University, This study was designed to determine the incidence
Salah Aldin, Iraq and significance of persistent nasal obstruction after
septorhinoplasty with different external nasal deformities.
Email: [email protected]
To recognize the anatomical structures that cause
persistent nasal obstruction and their surgical correction.
491 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 491

Patients and Method from the study. Preoperative photograph and operative
notes of primary septorhinoplasty were reviewed for
A prospective case study of 230 patients who
side and site of anatomical causes for septal deviation,
underwent closed septorhinoplasty during the period
turbinate, nasal valve area, and the operative procedure.
from January 2014 –June 2017 in Tikrit Teaching
Hospital and private practice in Salah-Eldin The patients were divided into two groups. Patients
Governorate,Iraq. The patients who had persistent who had external nasal deviation were 165 (71.7%),
nasal obstruction were and patients with no external nasal deviation were
39. They were collected when they visited the clinic for 65(28.3%).
follow up or by telephone contact follow-up surveys,
when the patient tells us that he has a nasal obstruction, The subjective sensation of patient about his or
ask him to attend the clinic for clinical examination. her postoperative nasal breathing was assessed by
All patients are clinically evaluated includes history, using Nasal Obstruction Symptom Evaluation(NOSE)
date of primary surgery, external nasal examination, scale(Table1).The questionnaire was administered to the
anterior rhinoscopy, nasal endoscopy and CT scan for patient to answer on the items. The NOSE survey
nose and paranasal sinuses. All patients the primary consists of 5 items, each have score on a scale ranging
surgery had been done at least since one year ago, and from 0 to
the nasal obstruction was secondary to anatomical nasal 4, and these scores were multiplied by 5, generating a
deformities. The patients who have nasal obstruction balanced scale from 0 to 100. Patients were categorized
due to nasal mucosal disease alone like as having mild (range, 5-25), moderate (30-50), severe
(rhinosinusitis, (55-75), or extreme (80-100) nasal obstruction5.
allergic rhinitis,non-allergic rhinitis) were excluded

Table 1: Nasal Obstruction Symptom Evaluation (NOSE) scale

Not a Very mild Moderate Fairly bad Severe
Item
problem problem problem problem Problem
1.Nasal congestion or stiffness. 0 1 2 3 4
2.Nasal blockage or obstruction. 0 1 2 3 4
3.Trouble breathing through my nose. 0 1 2 3 4
4.Trouble sleeping. 0 1 2 3 4
5.Un able to get enough air through my
0 1 2 3 4
nose during exercise or exertion.
Findings 22/110 (20%) , and in deviation to one side was 5/36
(14%) (Figure 1) (Table 2 ) Patients without external
The study showed that 39 patients (17 %) presenting
nasal deviation the nasal obstruction was 5/65 (8%)
to the author with complaint of persisting nasal
(Table 3).
obstruction despite prior septorhinoplasty since more
than one year ago. 22 (56%) were males and 17(44%)
were females. Patients age ranged from 23-38 years,
with a mean of 25.3 years.

The grading of nasal obstruction according to

(NOSE)scale was : Patients with mild nasal obstruction
12 (5%), moderate nasal obstruction 23 (10%),and
severe nasal obstruction 4 (2 %). No patient with
extreme nasal obstruction.

The post septorhinoplasty nasal obstruction were

Figure 1: Bar chart shows the severity of nasal
common in patients with deviated nose 34/165 (20.6%) ,
obstruction post septorhinoplasty related to the
in S-shape nasal deviation was 7/19 (37%) ,C-shape was external nasal deviation
Table 2: The relation between type of deviated nose and severity of nasal obstruction
Type of external nasal deviation
Total
Nasal obstruction C-shape deviation S-shape deviation Deviation to one side
Number % Number % Number % Number %
No nasal obstruction 88 80 12 63.2 31 86 131 79.4
Mild nasal obstruction 8 7.2 1 5.3 1 2.8 10 6
Moderate nasal obstruction 12 11 4 21 4 11.2 20 12.2
Severe nasal obstruction 2 1.8 2 10.5 0 0 4 2.4
Total 110 66.7 19 11.5 36 21.8 165 100
Chi square(ᵡ 2) = 9.36, d.f.=6, P-value= 0.01, Correlation=0.231

Interpretation: There is no significant association between severity of nasal obstruction and type of external nasal
deviation.

Table 3: The relation between external nasal deviation and severity of nasal obstruction
Non deviated nose Deviated nose Total
Nasal obstruction
Number % Number % Number %
No nasal obstruction 60 92 131 79.4 191 83
Mild nasal obstruction 2 3 10 6 12 5.2
Moderate nasal obstruction 3 5 20 12.2 23 10
Severe nasal obstruction 0 0 4 2.4 4 1.8
Total 65 28.3 165 71.7 230 100
Chi square(ᵡ 2)= 5.93, d.f. =3, P-value =0.01

Correlation: There is no significant association between external nasal deviation with occurrence and
severity of
nasal obstruction.
From a total 39 patients with nasal The 26 patients who underwent surgical treatment
obstruction,26(66.7%) was treated surgically and 13 for their nasal obstruction the endoscopic examination
(33.3%) with medical treatment (Table 4). and CT scan has been showed that 18 (69.2%) had nasal
septal deviation, 11(42.3%) had hypertrophied inferior
Table 4: Options of treatment of nasal obstruction turbinate ; 6 (23%) had nasal valve collapse; 2(7.7%)
had concha bullosa; and one patient (3.8%) had
Number synechiae between septal mucosa and inferior turbinate.
Treatment options (%)
(n = 39)* (Table 5)
Medical treatment 13 33.3
Table 5: Anatomical pathology of persistent nasal
Revision Septorhinoplasty 4 10.2
obstruction in 26 patients who treated surgically
Revision endonasal septoplasty 11 28.2
Extracorporeal septoplasty 3 7.7 Obstructive Anatomical Number Percentage
Reduction of inferior turbinates. 11 41 pathology (n = 26)* (%)
Endoscopic resection of lateral Septal deviation 18 69.2
2 5.1
border of concha bullosa. Hypertrophied inferior
11 42.3
Placement spreader graft. 6 (on 9 sides) 15.4 turbinates
Division of synechiae. 1 2.6 Nasal valve collapse 6 23
Concha bullosa 2 7.7
*The total number of patients in the column is 51
instead of 39,because multiple treatment modalities are Synechiae 1 3.8
*Total number of patients in the column is 38 instead
implemented in many patients. of 26,because several patients have multiple pathologies.
The anatomical locations of septal deviation in However, the observed difference in the occurrence
18 patients who underwent revision septoplasty, were of persistent nasal obstruction between deviated nose
caudal septal deviation 6 patients (33.3%), Mid septum than non- deviated nose and between the types of
bony-cartilaginous junction 4 (22.2%), Dorsal septum external nasal deviation. (Table 2,3),(Figure 2), these
deviation 3(16.7%), Bony septum spur 2 (11.1%) results Interestingly were not statistically significant
( one vomerine spur and one maxillary crest spur ),and
Multiple sites was in 3 patients (16.7%). Persistent nasal obstruction is one cause that made
patients seeking revision surgery. Kathy Yu.(2010)
The surgical techniques performed were revision noticed (62%) of patients seeking for revision
septoplasty for 14 patients ( 53.9%){ Endonasal rhinoplasty were experienced nasal obstruction 12.
septoplasty for 11 and extracorporeal septoplasty for Thomson (2007) demonstrated that the Major indication
3 },revision septorhinoplasty for 4 (15.4%),reduction for revision rhinoplasty was air way obstruction in
of inferior turbinate in 11 (42.3%), spreader graft (59.2%) then cosmetic causes 13.Gerhard (2007)
placement in 6 patients(23%) on 9sides, Endoscopic reported that breathing problems are the main complaint
resection of lateral border of concha bullosa 2 in 70% of the patients for revision rhinoplasty, and 10%
(7.7%),and synechiolysis in one patient (3.8%) (Table of the patients complain about residual or new breathing
4 ). problems after primary rhinoplasty3.

There were no statistically significant association Deviated nose is mostly due to caudal and dorsal
between severity of nasal obstruction and type of cartilaginous deviation.Therefore the surgeon who
external nasal deviation(Table 2), and no association concentrate on the cosmetic outcomes, may be missed
between external nasal deviation with occurrence and inferior bony spur, hypertrophied turbinate or large
severity of nasal obstruction (Table 3). concha bullosa. Other reason for missing anatomical
nasal obstruction is that the CT scan for the and
Follow up for a minimum 6 months, the nasal paranasal sinuses was not routinely performed as pre
obstruction was relieved in all cases. Asymptomatic operative preparation for septorhinoplasty, that may
septal perforation was occur in 2/18 patients (11.1%) results in a defect nose in preoperative assessment.
who underwent revision septal surgery.
The patient’s satisfaction about his or her nasal
obstruction after septorhinoplasty has variable results
Discussion
according to surgeon’s experience from (84%)14
The current study is considered the first on (90%) and (91.5%) . Foda (2013) was demonstrated
15 16 17

persistent nasal obstruction follows closed that 76% of the patients with crooked nose were
septorhinoplasty, that compares between the different reported improved breathing post septorhinoplasty.
types of deviated nose and non-deviated nose. Most
The medical treatment includes steroids,
studies have only focused on persistent or recurrent decongestants, and antihistamines, that was found to
nasal obstruction after septoplasty or rhinoplasty alone. improve nasal obstruction in (33.3%) of patients with
1,6,7,8
. mild and moderate nasal obstruction. Despite there
The nasal septum deviation in the deviated nose are no medications correct anatomical obstruction,but
is commonly of traumatic cause 9, where multiply medication can decreasing mucosal swelling due
fractured bony and cartilaginous septum, and abundant to rhinosinusitis, allergic or non -allergic rhinitis to
maximize nasal opening.
scar tissue,this made septoplasty to be quiet difficult 7.
The patient who have a grossly deviated septum, the The defective nasal septum due to aggressive
persistent septal deviation may be due to failure of septoplasty that may be indicated for severely deformed
correction of original anatomical cause. Sometimes nasal septum, with an unknown amount of cartilage
despite a perfectly straight nasal septum was achieved or bone present, and disrupted tissue planes all made
in primary surgery, it may be different one year later 10. revision septoplasty is a challenging procedure as
The cartilage memory and scar contracture predispose difficult dissection in compromised nasal septum with
to recurrence of the deviation 11, if the cartilage memory subsequent septal perforation that occurs in (11.1%).
is not altered sufficiently, it often returns over time to its It
initial curvature.4
is important that in revision septoplasty to palpate the severe problem for each item on the questionnaire
septum to find the areas of excised septal bones and or (Table
cartilage before attempting any septal flap elevation. 1), this has made it difficult to determine the grade of
Extracorporeal septoplasty was performed in 3 patients, nasal obstruction accurately. If the symptoms of each
when the author found that it is difficult to get stable and problem have been clarified the answer will be accurate.
straight nasal septum by endonasal septoplasty. In this study used the closed septorhinoplasty approach,
our future perspective of this study to compare our
Revision functional septorhinoplasty was performed results with open septorhinoplasty approach.
to 4 from 230 patients who underwent septorhinoplasty
(1.73%). Emily (2016) reported (2.5%) of revision
Conclusion
functional septorhinoplasty was performed because of
nasal airway obstruction18. The study has found that most of patients with nasal
obstruction were relieved by septorhinoplasty. There
Adjunctive turbinate reduction is advisable in
was no statistically significant association between
patients underwent septorhinoplasty 9,this will increase
external nasal deviation with occurrence and severity
the cross-sectional area at the nasal valve 7 and will
be improve nasal breathing The author used (Out- of nasal obstruction ,and not between severity of
fracture of the turbinates with microdebrider assisted nasal obstruction and type of external nasal deviation
submucosal turbinoplasty). Although the proper after septorhinoplasty. It was observed that nasal
treatment of underlying causes for turbinate hypertrophy septal deviation was the common anatomical cause of
are important to obtain good long term results after persistent nasal obstruction. The surgical planning for
turbinate surgery19. septorhinoplasty must be taken in consideration the
improving nasal air way, as well cosmetic outcome,
The internal nasal valve obstruction in deviated to avoid revision septal surgery that are challenging
nose was frequently caused by caudal septal operation with risk of septal perforation.
deviation
20
,and should be considered in patients with a severe Ethical Clearance: from research ethic committee in
dorsal deflection and a narrowed middle vault 21,if it is Tikrit university/college of medicine
not recognized and corrected during the operation, will
Source of Funding: Self
contributes to post-septorhinoplasty nasal obstruction 4.
Serhan (2016) report alar collapse was seen in 6% of Conflict of Interest: None
the patients with persistent nasal obstruction follows
septoplasty 8. Khosh (2004) found (79%) of patients
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2. ThomasRomo, MD, FACS.Postrhinoplasty
and secured in a tunnel, when the septal cartilage has
Nasal Obstruction Rhinoplasty.Otolaryngology
been separated from upper lateral cartilage,the graft
and Facial Surgery.Oct 25, 2018:Available
fixated with transcutaneous and transseptal sutures was
from:https://emedicine.medscape.com /
placed on 4 sides.
article/841574.
A limitation of this study is that many patients 3. Ozan Kuduban, FatihBingol, et al. The Reason
encounter difficulty in responding accurately on the of Dissatisfaction of Patient after Septoplasty.
NOSE scale survey. The (NOSE)Scale is a valid,
EurasianJof Medicine; Avialable from “https://
reliable, and responsive instrument 23,but the
www.eajm.org/sayilar/196/buyuk/6”
questionnaire required intelligent respondents to give
information, the simple patient has difficulty particularly 4. Michael J. Sillers, ArtemusJ,et al. Revision
to determine the differences from the very mild, Septoplasty.Otolaryngol Clin N Am 42 (2009)
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14. P.borges Dinis, M.Dinis,A.Gomes. Psychological

consequences of nasal aesthetic and functional
DOI Number: 10.5958/0976-5506.2019.01619.X

Diagnosis of Trichomonas Vaginalis Infection by Detection of

Glutaminase (Glut) Gene by Nested PCR

Faten Ahmed Hassan1, Huda Dhaher Al-Marsomy2, Suhad Asaad Mustafa3

1
Children Welfare Hospital, Medical City, Baghdad, Iraq; 2Department of Microbiology, College
of
Medicine, Al-Nahrain University, Iraq; Salahaddin University-Erbil, Kurdistan region of Iraq
3

ABSTRACT
Trichomonas vaginalis (T. vaginalis) is a common pathogen with a cosmopolitan distribution.
Trichomoniasis is associated with vaginitis, cervicitis, low birth weight, preterm delivery, and infertility.
Glutaminase (glut) p3 gene which is a housekeeping gene increases the detection of T. vaginalis
efficiency when used as a marker of Trichomoniasis. In this study (glut) P3 gene was depended for
parasite detection by nested PCR and compared with conventional methods like wet mount and culture
in the detection of T. vaginalis in vaginal discharge. Two vaginal swab specimens were obtained
from 157 cases, of (mean age = 31.79 ±
9.21 years), both symptomatic and symptomatic females attending Gynecology OPD of Al-Emamayn Al-
Kadhimayn Medical City in Baghdad and Maternity Teaching hospital in Erbil province, Iraq. One swab
was immediately examined by wet mount microscopy and then placed in CPLM medium for cultivation,
and another swab is placed in PBS buffer for PCR method. A total of 100 samples positive in one or more
tests were identified: 20 (12.7%) infections were detected by wet mount microscopy, and 30 (19.1%)
positives in culture. P3 nested PCR was positive in 100 (63.7%) samples. PCR appears to be the most
sensitive method with high detection rate and method of choice. Furthermore nested PCR increases the
sensitivity and specificity of PCR, and Glutaminase (glut) p3 gene can be efficiently used for detection of
T.vaginalis.

Keywords: T.vaginalis; Glutaminase (glut) p3 gene; nested

PCR
Introduction females, however, infections can persist for many years,
and symptoms, mainly pruritus caused by inflammation
T. vaginalis is a globally occurring anaerobic/
and odorous vaginal discharge, can attain a severity
microaerophilic protist parasite which settles down the
which is debilitating 5-7. A large number of studies
epithelium of the human urogenital tract 1. T.vaginalis
from the last 30 years or so, however, have shown that
infections can cause inflammation in the cervix, the
underlying T.V. infections increase the risk of adverse
vagina, and the urethra 2. Based on estimates of the
pregnancy outcomes and contagion with HIV virus (2
World Health Organization (WHO) from 2016 3,
to 2.5) 8. Diagnosis of trichomoniasis cannot be made
trichomoniasis constitutes the most prevalent non-viral
solely on the basis of clinical presentation, because the
sexually transmitted disease (STD) worldwide, affecting
clinical symptoms may be synonymous with those of
approximately 160 million people every year. Males and
other STDs 9, so various laboratory methods have been
females are infected with comparable frequency, but in
employed for the detection of T. vaginalis in vaginal
male’s symptoms are normally mild, and infections are
discharge which varies in their sensitivity and specificity
cleared by the host’s immune system within weeks 4. In 10
. Wet mount microscopy is a simple, rapid, and
inexpensive while culture in a microaerophilic condition
Corresponding Author: is more sensitive 11. There are many cultures used for T.
Huda Dhaher Al-Marsomy vaginalis isolation and detection such as Kupferberg’s
Department of Microbiology, medium Diamond medium, Feinberg’s medium.
College of Medicine, Al-Nahrain University, Iraq Cysteine/Peptone/Liver infusion/Maltose (CPLM) and
Phone: +9647703440493 In-pouch TV system. Culture techniques have not been
Email: [email protected]
readily available but would be the most effective
way
497 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 497

of establishing the true epidemiology of T vaginalis 12. and referred to outpatient’s gynecology ODP at Al-
Molecular assays provide distinct advantages over other Emamayn Al-Kadhimayn Medical City in Baghdad
types of diagnostics because screening for Trichomonas and maternity Teaching hospital in Erbil province, Iraq.
has a high potential for identifying previously missed Clinical manifestations of infected women included
infections. PCR is based on DNA amplification and purulent vaginal discharge, purities, dyspareunia,
detection using known primers to T.vaginalis specific leucorrhoea, and dysuria. At the time of per-speculum
genes. In addition, Multiplex PCR appeared more useful examination, two vaginal swabs from the posterior
for simultaneously detect coinfecting pathogens. Real- fornix and also touching both lateral fornices and middle
time PCR assays were used in a number of studies to third of the vaginal wall were taken, using sterile cotton
test for T. vaginalis DNA, targeting the β-tubulin genes, swabs. Specimens collected prior to disinfection or local
revealed that the sensitivity of this technique was more antibiotic used for routine microscopic examination and
than culture and wet mount 13. A nested PCR is one in to inoculate culture medium, while the second one was
which the product of a PCR is subjected to the second placed in 0.5ml of PBS and submitted to the molecular
round of amplification using primers internal to those laboratory for PCR testing.
employed for the first round. Nested strategies increase
Wet mount preparation: The swab inoculated with
the sensitivity of the assay enormously14.
vaginal discharge for each patient was gently agitated
Patients and Method in one drop of normal saline on a clean slide and then
covered with a coverslip. The wet mount was examined
Samples: High vaginal swabs (157) were collected with 40 objectives, and the presence of motile T.
from symptomatic and asymptomatic women (mean vaginalis was detected by the characteristic twitching
age = 31.79 ± 9.21 years) suspected to motility (Fig.1).
trichomoniasis

Fig. 1: Wet mount method in detection of T. vaginalis (arrow)

Cultivation: Trichomonas modified dispensed into glass containers. Then two of these
cysteine/peptone/ prepared medium containers were incubated overnight
liver-infusion maltose Culture Medium (CPLM). at 37 ºC for sterility testing. Before inoculation of the
medium, the culture universal bottles were warmed up
This medium was prepared as follow:
to 37Co for 15min. The vaginal swabs were placed into
Fifty-six gram of medium was suspended with the medium and left to incubate at 37 Co for 7days. The
900 ml of distilled water, and then the mixture was cultures were examined microscopically on days 2, 5
sterilized using autoclave at 121 ºC for 15 minutes. The and 7 after inoculation. A positive result is defined as
medium cooled down to 50ºC, then 10 ml of inactivated the presence of motile T. vaginalis at any time; a
horse serum and 1 ml of antibiotic solution (50 µg of negative result was defined as the absence of motile T.
gentamicin/ml, 40 µg of ciprofloxacin/ml, and 50 µg vaginalis at all readings.
of miconazole/ml) were added before the medium
was
Fig. 2: Culture method in the detection of T. vaginalis (arrows)

DNA Extraction: A ready gSYNCTM (Geneaid England) DNA kit (Catalog no. GS100) was used for DNA
extraction (according to the manufacturer instructions).

Nested PCR primers: The primers based on T. vaginalis (glut) p3 gene for PCR identification were used.
The
sequences of primers were as follows:

Glutaminase (glut)P3 (outer): F AAACGCTGGTGCCATTACAAC

R AAGGTTCTTGCCACGGATTG
Glutaminase (glut) p3 (inner): F TCGTTAATAGTGGGTAAGGACG
R CCAAGTATAGCTCCGCTGAC

PCR protocol: PCR reactions for the first rounds were Gel electrophoresis: PCR amplification products were
performed with an automated thermocycler. The total visualized under UV light (trans illuminator) after
volume of PCR reactions was 25μl, 12.5 μl of the master electrophoresis on 1.5 % agarose gels in Tris-acetate-
mix, 3μl of the DNA extracted, 3μl of forward and EDTA buffer pH 8.5 (30 min at 5 V/cm) and staining
reverse outer primers and 6.5μl were added to the PCR with ethidium bromide (0.5µg/ml). The size of the
tube. The amplification was performed in the PCR amplified products 451 (bp) was assessed by comparison
tubes, and the procedure is as follows: with a commercial weight marker 100-1000 (bp), Smart
Ladder (Bioneer|Korea) and photographed by the digital
The first round program
camera.
Initial Denaturation: 95°C- 5 minutes.1 cycle.
Subsequent denaturation: 93 Co- 30 seconds.35 cycles.
Annealing: 57Co-30 seconds.
Extension: 72 Co- 1.0 minute.
Final Extension:72Co-10 minutes.1 cycle.
Termination: 4 Co to time end.
The second round program:
Initial Denaturation: 95C°- 5 minutes.1 cycles
Subsequent denaturation: 95 Co- 1.0 minutes.40 cycles.
Fig. 3: Gel electrophoresis of glutaminase (glut) P3
Annealing: 57Co-1.0 seconds. gene amplified with specific primers. Lane A,
Extension: 72 Co- 1.5 minute. negative result while lanes B,C,D,E,F,G,H,I,J,K,L,S
Final Extension:72Co-10 minutes.1 cycle. and N were positive (451 bp). M: molecular marker.
Termination: 4 Co to time end. Sequencing: Gene sequences were analyzed to
ensure
that the sequences were from T. vaginalis.
Amplicons
(20 μl) were sent for purification and sequencing to with antibiotics to eliminate vaginal flora, causing the
Macrogen (South Korea), using the Big Dye Terminator transmission from fast growing to slow growth of the
method. Sequencing was performed bi-directionally parasites 19. Incubation periods ranging from 2-7 days
using the same primers used in PCR amplification of the are required to identify T vaginalis in culture, and the
(glut) p3 gene. need to delay treatment until the results are available 20.
In the present study, nested PCR rather than culturing
Results was considered the gold standard for T. vaginalis
detection. Accordingly, the sensitivity and specificity of
Three laboratory methods were utilized for detection culture, and wet mount were 32% and 100%; 20%
of T. vaginalis in this study (Table. 1). PCR positivity and
for T. vaginalis, was considered a gold standard to 100% respectively. These results partially agree with the
compare the other methods. Culturing came second with different studies in this regard. In a local study, Kareem
an overall efficiency of 32%. Finally, wet mount came M. (2017) 21, investigated 200 women (age range 15-
last with an overall efficiency of 20% Accordingly the 54 years) with abnormal vaginal discharge using two
sensitivity and specificity of culturing, staining and wet laboratory methods: wet mount, and real-time PCR.
mount were 32% and 100%; 26% and 100%; 20% The detection rate of T. vaginalis was 12.5% and 17%
and respectively. Similarly, Merdaw M. (2016) 22 used wet
100% respectively. mount and culturing method for T. vaginalis detection
in vaginal swabs from 154 women (age range 15-54
Table 1: Sensitivity and specificity of wet mount and years). Culturing had a priority in the detection of this
culture in comparison with PCR protozoon (34.41%) compared with wet mount (13.63).
In the present study the single copy housekeeping
Investigation Total gene, Glutaminase (glut) p3 23, were subjected to two
Sensitivity 20.0% successive rounds of nested PCR, furthermore, the
Wet mount
Specificity 100% outer and inner sets of primers used in the annealing
Sensitivity 32.0% step of amplification process were retested by NCBI for
Culture specificity to T.vaginalis Glutaminase (glut) p3 gene and
Specificity 100%
not to human, other trichomonads, nor any organisms
registered in Genbank. The detection rate was very high,
Discussion diagnosing one hundred positive T.vaginalis infection
Rapid and sensitive diagnosis of T. vaginalis in (non-cultured) clinical samples obtained from
infection is important for appropriate treatment and to symptomatic and asymptomatic women in comparison
reduce the spread of the disease. Although wet mount to only seven isolates of Merdaw or the 17% detection
7

is routinely performed for this purpose, this technique rate of Kareem. Globally, many studies reported that,
has a low sensitivity 15. The present study showed low PCR appears to have high sensitivities and excellent
sensitivity of wet mount method; it was 20% when specificities for vaginal samples than wet mount and
compared with PCR, whereas 80 positive samples would culture and it requires expertise and availability . Dr.
17

have been missed if PCR not had been used. The false- Kiranmai and Dr. A. Neelima (2016) in India, they
24

negative test can result from many variables include analyzed a number of clinical samples by wet mount,
low parasite load, the time interval between specimen culturing in Whittington medium, and conventional PCR
collection and microscopic examination (>10 minutes), based on amplification of T. vaginalis β-tubulin gene
and clinician skill 16. T. vaginalis is perishable in in 200 females, concluded that none of the diagnostic
external conditions; it loses its motility, retracts its assays could detect all positive samples, but PCR
flagella and change its morphology by becoming showed a higher detection rate than others in the
rounder (may call pseudocysts) and then becomes detection of T. vaginalis in vaginal swab samples.
difficult to be distinguished from similar structures, Culha et al. (2015) compared the efficiency of three
such as leucocytes methods (wet mount, culturing on trypticase-yeast
17,18
. Although culture method is more sensitive than extract-maltose (TYM), and conventional PCR) for
wet-mount microscopy, the main limitations for its detection of T. vaginalis in clinical samples from 200
routine use include the cost, contamination with bacteria symptomatic Turkish women (age 20-50 years).
(major problem), even with broth cultures spiked Surprisingly, the detection rate of wet
mount and PCR was equal (42.8%), while the detection sperm cells: adhesion seems to be a prominent
rate for culturing method was 32.1%. The authors stage during the interaction. Parasitol Res.
demonstrated that there was no statistical superiority for 2008;
PCR over the wet mount. In accordance with the present 102: 597-604
result is a recent study conducted in an STD clinic in
5. Pellati D, Mylonakis I, Bertoloni G, Fiore C,
Alabama in which the prevalence of T. vaginalis
Andrisani A, Ambrosini G, Armanini D. Genital
was
tract infections and infertility. Eur J Obstet
19.6% by wet mount and 27% by NAATs (Muzny et
Gynecol Reprod Biol. 2008; 140:3-11.
al., 2014) 25. Furthermore, Nathan et al. (2015) 26, stated
that wet mount is only 40-60% sensitive even among 6. Shiadeh MN, Niyyati M, Fallahi S, Rostami A.
symptomatic women, and the nucleic acid amplification Human parasitic protozoan infection to infertility:
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The incidence of T. vaginalis infection was quite
of epidemiologic, clinical and treatment issues.
high in symptomatic and asymptomatic infected women.
BMC Infect Dis.2015; 15: 307.
Diagnosis of T. vaginalis can be efficiently made by
detecting Glutaminase (glut) p3 gene other than Actin 9. Passos M, Camposarze W, Mauricio C, et al. Is
or Beta-tubulin genes and nested PCR test in this study there an increase in STDs during carnival? Time
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Conflict of Interest: The author declares no conflict of 10. Radonjic IV, Dzamic AM, Mitrovic SM, et al.
interest. Diagnosis of Trichomonas vaginalis infection:
The sensitivities and specificities of microscopy,
Source of Funding: This research did not receive any culture and PCR assay, Eur. J. Obstet. Gynecol.
specific grant from funding agencies in the public, Reprod. Biol. 2006; 126(1):116-120.
commercial, or not-for-profit sectors.
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signed an informed consent form, detail of the method vaginalisGary E Garber, MD FRCPC16(1): 2005;
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DOI Number: 10.5958/0976-5506.2019.01620.6

Burnout Syndrome among Physicians Working in Primary

Health Care Centers in Baghdad, Al-Rusafa Directorate, Iraq

Abdul Munem Al Dabbagh1, Ali Hassan Hayyawi2, Maha Saber Kochi3

1
Professor, Chair of Iraqi Board in Family and Community Medicine; 2Community Medicine specialist
Al- Yarmouk Teaching Hospital, Baghdad, Iraq; 3Family Medicine Specialist, Baghdad, Iraq

ABSTRACT
Introduction: Burnout syndrome has been one of the most widely discussed mental health problems.
Subjects and Method: A cross-sectional analytic survey conducted in a primary health care centers.
Results: Most of the respondents who had high burnout were working at primary health center
(33.3%),
General Practitioner (33.3%).
Keywords: Burnout, Exhaustion, Job stress
Introduction Rationale: In Iraq we believe that physicians
are over whelmed by the daily workload during the
The phenomenon of “burnout” emerged as a major
formal working hours this may lead to frustration and
social issue in the United States in the mid-1970.
psychological distress; in addition, many social and
Burnout is a potential problem within a wide range of cultural issues contribute to the negative effect of being
occupations such as medical staff, teacher, and social overloaded by work. And because little is known about
worker (1). professional burnout, job satisfaction, and motivation
In recent years, burnout syndrome has been one among physicians working in primary health care centers.
of the most widely discussed mental health problems The current study was sought to shed the light on
in modern societies. In a world that faces major the extent of burnout among physicians working in
socioeconomic challenges people experience ever- the primary health care centers, and to find out factors
increasing pressure in their daily lives, particularly at associated with occurrence of burnout syndrome among
the workplace (2)(3). the selected sample group.
Globally many studies had been conducted
addressing burnout among “Medical Professionals” like Subjects and Method
the one conducted in United State (4), and in Europe (5).
A cross-sectional analytic survey. The study was
Regionally in Qatar (6), in Saudi Arabia (7), and in Iran (8).
conducted in Primary Health Care Centers (PHC) of six
Nationally a study conducted among physicians sectors that constitute the central region of Al-Rusafa
had documented moderate emotional exhaustion (EE), Health Directorate/Baghdad. Fifty percent of PHCs
high depersonalization (DP), and moderate personal were selected randomly from a list of each sector. Data
accomplishment (PA) (9). were collected from first April till the end of June 2017.

A convenient sample of 134 physicians from the

randomly selected PHCs was asked to participate in this
Corresponding Author: study. Six physicians refused to participate in the study
Ali Hassan Hayyawi, PhD (CM) gave a response rate of (95.7%). All physicians who
Community Medicine Specialist had at least one-year work at the center, and available
Al-Yarmouk Teaching Hospital, Baghdad, Iraq during period of study represented the targeted study
Phone: 00964 7902483159 population.
Email: [email protected]
503 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 503

Data Collection tool: The data was collected by was married and those who had 1-3 children constituted
researchers through previously prepared and validated 79.3% of study group, 64.9% of participants were
self-administered questionnaire. The questionnaire working at PHC and 83.6% of them had no managerial
used consisted of two Parts: First part: concerned with position. Most of the participants were holding the
informations about socio-demographic and educational Bachelor educational level (59.7%). and the majority
characteristics of study participants; Second Part: using was nonsmokers (86.6%). More than two third (73.1%)
Maslach Burnout Inventory (MBI) to assess the burnout of respondents had no chronic illness.
status which consisted of three domains: Emotional
exhaustion (9 questions); Personal accomplishment Table 1: Essential characteristics of respondents
(8 questions); Depersonalization (5 questions). Each
question is rated according to the frequency of occurrence Characteristics N %
on seven points Likert scale from zero (never), one (few/ <30 12 9.0
year), two (monthly), three (few/month), four (weekly), Age group 30-39 64 47.7
five (few/week) to six (daily). Burnout syndrome is ≥40 58 43.3
multidimensional construct therefore the sub-scales are
Male 47 35.1
combined to reveal one burnout ultimate score. As a final Gender
result the high burnout in this study was defined as high Female 87 64.8
scores of emotional exhaustion high depersonalization Marital Single 23 17.2
and high reversed personal accomplishment. Eventually status Married 111 82.8
the scale of burnout was categorized as low when the No of 1-3 88 79.3
total score (1-33), moderate (34-66) and high (67-99.9)(10). children ≥4 23 20.7
Pilot study: was carried out on 10 physicians (who were Bachelor 80 59.7
not included in final study). Education
Diploma 15 11.2
level
Doctorate 38 28.4
Ethical Consideration: A formal clearance was taken
from the Ethical Committee of Al-Rusafa Health Primary health center 87 64.9
Work place
Directorate/Baghdad, and additional consent was Family health center 47 35.1
taken from the chosn six health sectors. Moreover, the General practitioner 81 60.5
researchers obtained verbal consent of all participants. Family physician
Job title 46 34.3
specialist
Statistical Analysis: Data were imported to statistical
package for social sciences (SPSS) version (23). Other specialty 7 5.2
Assuming that our data was approximating normal Managerial No 112 83.6
distribution, for that we use parametric test of position Yes 22 16.4
significance but not non-parametric test used usually No 116 86.6
with data obtained by this scale. Chi-square test was Smoking
Yes 18 13.4
used to explore the existence of a statistically significant
relationship between the categorical variable. P value ≤ No 98 73.1
0.05 were considered statistically significant. Various Hypertension 16 11.9
multilevel logistic regressions with cross effects to Chronic
Ischemic Heart
disease 12 9.0
investigate the connection between having burnout and Disease
the factor associated with burnout syndrome. Diabetes Mellitus 8 6.0

Results Table 2 shows the average scores of subscales of the

MBI human service survey (MBI-HSS). Mean scores
The socio-demographic characteristics of showed high EE, high PA, and low DP (31.01, 33.17,
participants are shown in (table 1). The majority of the and
participants were between (30-39) years of age (47.7%),
8.66) respectively. Cronbach alpha coefficient for three
mostly female (64.8%). Also 82.8% of the study
MBI subscales indicates the reliability of the instrument
group
for measuring burnout syndrome among physicians.
Table 2: Average score of the MBIs subscales
Burnout Domains Mean Standard Deviation Median Cronbach alpha
Emotional exhaustion 31.01 14.441 31.0 0.895
Personal accomplishment 33.17 10.285 35.0 0.848
Depersonalization 8.66 6.536 8.5 0.701
Burnout syndrome 54.50 23.148 56.0 0.702

Prevalence of burnout based on each subscale of MBI showed that the majority of participants had high EE,
high PA and low DP score (68.7%, 41.1% and 45.5%) respectively. On other hand half of participants had moderate
burnout (50.0%) (table 3).

Table 3: Prevalence of burnout based on each subscale of MBIS

Level of burnout
Burnout domains (N = 134)
Low n (%) Moderate n (%) High n (%)
Emotional exhaustion score 26(19.4) 16(11.9) 92(68.7)
Personal accomplishment score 44(32.8) 35(26.1) 55(41.1)
Depersonalization score 61(45.5) 38(28.4) 35(26.1)
Burnout syndrome score 26(19.4) 67(50.0) 41(30.6)

Table 4 illustrates the association between demographic characteristics and burnout syndrome. There were
significant association between burnout syndrome and age, marital status. (p = 0.03, p = 0.012) respectively, but no
significant association were found with work place, job title, and managerial position.

Table 4: Relationship of burnout syndrome with some essential characteristics of the study group
Burnout
Low Moderate High Total Test*
n(%) n(%) n(%) n(%) p-value
<30 2(16.7) 2(16.7) 8(66.7) 12(100)
10.736
Age groups 30-39 12(18.8) 31(48.4) 21(32.8) 64(100)
.030**
=>40 12(20.7) 34(58.6) 12(20.7) 58(100)
Male 9(19.1) 23(48.9) 15(31.9) 47(100) .060
Gender
Female 17(19.5) 44(50.6) 26(29.9) 87(100) .971
Single 3(13.0) 7(30.4) 13(56.5) 23(100) 8.803
Marital status
Married 23(20.7) 60(54.1) 28(25.2) 111(100) .012**
Bachelor 12(15.0) 41(51.3) 27(33.8) 80(100)
5.317
Education level Diploma 5(31.3) 5(31.3) 6(37.5) 16(100)
.256
Doctorate 9(23.7) 21(55.3) 8(21.1) 38(100)
Primary health center 14(16.1) 44(50.6) 29(33.3) 87(100) 2.025
Work place
Family health center 12(25.5) 23(48.9) 12(25.5) 47(100) .363
General practitioner 13(16.0) 4150.6) 27(33.3) 81(100) 1.846
Job title
Family medicine specialist 13(24.5) 26(49.1) 14(26.4) 53(100) .764
Managerial No 24(21.4) 52(46.4) 36(32.1) 112(100) 3.716
position Yes 2(9.1) 15(68.2) 5(22.7) 22(100) .156
Total 26(194) 67(50.0) 41(30.6) 134(100)
* Chi-square test with Bonferroni correction, ** Significant test
Multinomial logistic regression analysis is The odds ratio of marital status indicates that being
expressed in table 5; the reference category is the low married had about twice more relative risk than single
burnout group. When age increased by one year both to had moderate burnout score but had no effect on high
moderate and high burnout scores, tend to be decreased burnout score.
by 0.022 and 0.091 (2.2%, 9.1%) respectively.
The highest effect on relative risk to develop
Job title affected the moderate burnout by a moderate burnout score in relation to low score was for
reduction the participants who attend managerial position with
of 0.14 but has no effect on high burnout group. odds ratio of (3.013). While smoking had odds ratio
of
Age significantly affect high score burnout in 3.8 with nearly four times increase in relative risk to
relation to low score level when all other variables are develop high burnout.
set at zero level. Other variables have got p-value more
Those with chronic diseases have about one and a
than 0.05, which indicate uncertain role in prediction half relative risk to develop moderate burnout state and
of getting moderate and high burnout compared to low nearly three times to develop high burnout in
burnout. comparison to low burn out as referral categories.

Table 5: Multiple logistic regression analysis for predictors among the study sample

95% CI
Exp
Burnout * B SE Wald df P-value Lower Upper
(B)
Bound Bound
Age -.022 .028 .624 1 .430 .978 .926 1.033
Gender .255 .588 .188 1 .664 1.290 .408 4.083
Marital status .672 1.039 .418 1 .518 1.959 .255 15.015
Number of children -.424 .591 .515 1 .473 .654 .205 2.084
Moderate
Type of work -.418 1.006 .173 1 .678 .658 .092 4.731
burnout
Jobs -.136 .987 .019 1 .891 .873 .126 6.038
Managerial position 1.105 .856 1.666 1 .197 3.018 .564 16.149
Smoking .599 .951 .397 1 .529 1.82 .282 11.736
Chronic disease .550 .640 .738 1 .390 1.733 .494 6.071
Age -.091 .036 6.586 1 .010 .913 .851 .979
Gender -.071 .698 .010 1 .919 .932 .237 3.662
Marital status -.088 1.174 .006 1 .940 .916 .092 9.146
Number of children -.700 .781 .803 1 .370 .497 .107 2.295
High
work place -.726 1.241 .343 1 .558 .484 .042 5.505
burnout
Job title .005 1.217 .000 1 .997 1.005 .092 10.920
Managerial position .177 1.017 .030 1 .862 1.194 .163 8.755
Smoking 1.326 1.034 1.646 1 .200 3.766 .497 28.549
Chronic disease 1.026 .779 1.736 1 .188 2.790 .606 12.837
B: regression coefficient, SE: standard error, Exp (B): odd ratio, CI: confidence interval
*
The
reference category is: Low burnout.
Discussion associated with absenteeism from work, interpersonal
conflicts, lower productivity, job dissatisfaction (12).
Occupational-related burnout is increasingly
nowadays recognized as a serious problem affecting The current study showed that prevalence of high
particularly health-care workers (11). Burnout has burnout syndrome was more than one-quarter this is
been
close to a study conducted by Oumaya among primary status and burnout in current study. Rate of burnout
care doctors who found that burnout prevalence was among
(33%) (13). While a study conducted among primary
health care physicians by Al Dubai and Rampal, who
found that burnout was at a rate of (11.7%) (14), another
study conducted in Qatar in 2011 concluded that
(12.6%) of the physicians experienced burnout (6). Also
study conducted in Saudi Arabia in 2013 showed that
the prevalence of burnout syndrome among physicians
was (7.3%) (7). This difference in results between Iraq
and other countries may be due to overburdened health-
care system in Iraq, lack of resources, difficult work
schedules with long hours of work and inadequate
security.

In the current study the large share of participants

described themselves as high EE (68.7%), high PA
(41.1%) and low DP (45.5%). These results are similar
to study conducted in Yemen in 2010 (14). But different
from a study conducted among physicians working in
Medical City teaching complex Baghdad/Iraq by
Mohammed in
2016 who found moderate EE, high DP and moderate
PA (9). Again similar to other study conducted by Hasan
et al in Bahrain in 2015 (15). The difference in the
prevalence of burnout syndrome and level of burnout
domains can possibly be explained by variation in career
aspirations among physicians, the nature of the health
systems, patient’s attitudes and the role of physicians as
healthcare providers. It may also be attributed to
different assessment scales used, and the study designs
used in the various studies.

In the current study the relationship between age

group and total burnout was statistically significant.
Physicians who were in the age group ≥40 years old had
low level burnout (20.7%). Contrary a study by Al
Dubai and Rampal in 2010 showed that low level
burnout syndrome was significantly associated with age
group below 40 years old (14). This difference may be due
to increase in financial security and cultural factors, in our
country patients look to older age with more respect and
trust.

This study showed no significant relationship

between burnout and gender, yet male was more prone
to burnout than female which is against the result of a
study done in Qatar in 2011 where the female was more
prone than male (9). The variation in result of the two
studies may be due to geographical factors, different
attitude toward female, and discrepancy in practice
toward gender.

Significant association was found between marital

single is more than its rate among married. These
findings were different from the findings of a study
conducted in Suez land/Egypt (16). The result in our
study may be attributed to the social support of the
spouse which might play buffering effect to protect
against burnout.

Burnout among physicians working at primary

health care center is slightly higher than that reported
among physicians working at family health center.
This is similar to the finding of a study conducted by
Abdulghafour in 2011 (17). This result may be related to
workload in primary health care centers in our country.

No significant association was found between

burnout and Job title in this study which is in congruence
with a study conducted by Abdulghafour in 2010 (17).
Also similar to a study conducted among PHC physician
in Egypt (16). This difference in results may be related
to different possible stress factors among general
practitioner and family physician.

The relationship between having burnout and

engagement in managerial position was also not
significant. However, there is lower burnout among
physicians who had managerial position (22.7%) than
those who had no managerial position (32.1%). This
unexpected results probably can be explained by that
some doctors who work efficiently and believe that they
are qualified to take up managerial positions, but they
are not assigned to these positions are exposed to
burnout at higher rate. On the other side those physicians
who had managerial positions may have some privileges
such as travels, dispatch, and some financial returns
making them happier with their jobs hence lower
burnout rate.

Recommendation: Measures should be taken to

overcome the stressor in workplace through,
occupational training programs, and providing necessary
resources.

Conflict of Interest: We declare that there was no

conflict of interest.

Source of Funding: Self

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DOI Number: 10.5958/0976-5506.2019.01621.8

Influence of Low Power He-Ne Laser on the Skin Thickness of

Swiss Mice

Zainab Abd ALjalil1, Ali Kamel Mohsin1, Ali Mahdi Mutlag2

1
Wasit University, College of science, Department of Physics; 2Wasit University, College of
Medicine
Department of Anatomy and Biology, Wasit, Iraq

ABSTRACT
The application of laser in dermatology and skin therapy is a key issue for numerous developments in
future. The helium–neon laser at 632.8nm wavelengths, with the power of 2 and 1.31 mW was applied on
the mouse’s skin at various time 10, 20 and 30 min for 20 days. The animals were divided into two groups;
control group, which didn’t radiate while the other group was divided in to three groups each one has two
mice where it exposed to the laser. The histological analysis was used only for those groups and studied
microscopically. Histological analysis showed a significant effect of laser and numerous differences
between the two groups. The thicknesses of the epidermis layer for the control group comparing with other
groups showed noticeable increasing. In addition the skin presents enhancing of the features and
architecture of layers. So, the low power laser has a good effect and amazing tool to enhance skin layer and
cells on it.

Keywords: low power laser, He-Ne laser, skin

enhancing.
Introduction [email protected]

The attractive properties of laser make it a useful

tool for several applications. Most of lasers are using in
biology, medicine and dermatology depends on
advanced technology and innovative laser systems for
diagnosis and therapy. Therapeutic laser is very special
and has a clear picture to illustrate how the radiation
interacts with tissues (1). Numerous current therapeutic
treatments can be quantified which means simply
producing a beam of radiation different from ordinary
light in several ways (2).

The skin is the largest organ in the human body and

comprises about 16% of body weight. The average
person can have about (1.8) meter squares of the skin-
encased body, which may be introduced to harsh
conditions (3).
Which shows the low‐Powerful lasers effect on the cell.
This vitro study focuses on the biostimulation fibroblasts

by a low‐Power Ga–As‐Pulsed laser

Corresponding Author:
Zainab Abd ALjalil
Wasit University, college of science
Department of physics, Wasit, Iraq
Email: [email protected]
Light can be scattered or absorbed when it
penetrates the tissue, and the extension of both processes
depends on the type of tissue and the excitation
wavelength. Absorption is mainly due to endogenous
chromospheres, such as haemoglobin, myoglobin, and
cytochromes. Scattering is generally the most relevant
factor in the determination of light penetration into the
tissue. Laser-tissue interaction is interesting due to it’s
the significant application in biomedical optics in both
diagnostic and treatment purposes. Major aspects of
the laser-tissue interaction, which has to be considered
in biomedical studies, are the thermal properties of the
tissue and the thermal changes caused by the interaction
of light and tissue. These effects depend on the peak
power and wavelength of the laser as well as the thermal
properties of biological tissues. The laser can increase
the temperature of cells. It results in denaturation of
proteins, and collagen that leads to coagulation of tissue
and it can necrotic cells (2). Here we present photo-
optical method that enables stimulation of skin cells by
the low power laser (He-Ne laser, 632.8nm).

Materials and Method

Animals: This study is carried out in physics
laboratories from the period of February to June 2018.
Fourteen white Swiss mice (four males and ten females)
conducted in this work of 14 weeks, were kept in animal
house of College of Sciences under condition (25–28 C
509 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 509

) temperature and control light (12–12 hour) supplied Before laser exposed, the animals anesthetized by
with food and water ad libitum. Mice were maintained in an injection of ketamine (80 mg/kg body weight). Then
cages (4 mice/cage), after 7 days of acclimatization, the the hair of animals has been shaved to increase the
animals were divided randomly into six experimental power strike the skin. The region was exposed to the
groups (n=2 of each group) and tow control group. As
He-Ne laser beam (wavelength 632.8nm, power
shown in the table below (2.1).
output
He-Ne Laser Exposed: Laser system that used in this = 2, 1.31 mW) with a 1mm diameter. The exposure time
work was manufactured by Lambda Scientific, class I was 10, 20 and 30 min to achieve the preferred doses at
visible laser (I-Laser, Austerely), as shown figure (1). present in table (1). The intensity of the laser was tuned
and reduced by a red filter.

Fig. 1: The helium neon laser device 632.8 nm, red filter and laser power meter device (LP1)

Table 1: He-Ne laser (632.8 nm) parameters used for irradiation of the mice skin
Spot size or Spot Energy of Energy Power
Exposure Power
exposure diameter laser beam E density or density DE Groups
time (min) (mW)
(cm2) (cm) (ev) x 10 +13 Dose (J/cm2) (W/cm)
X X X X X X X Control
0.0079 0.1 2.0833 2.548 0.2548 10 2 Group 1
0.0064 0.09 1.3644 2.047 0.2047 10 1.31 Group 2
0.0064 0.09 0.6825 4.094 0.2047 20 1.31 Group 3
0.0064 0.09 0.4549 6.141 0.2047 30 1.31 Group 4
Histological Procedures: The histological technique Results
done according to Bancroft and Steven (4). Throughout
several steps to form tissue paraffin blocks and The microscopic examination of the skin tissue
sectioning the steps as the following: for the control group is expected to complete by a light
1. Fixation microscope at different magnification (X 40 & x 100).
The results show the typical structures of the mice’s
2. Dehydration
skin. The sections show the epidermis of skin compose
3. Clearing
of stratified squamous keratinized epithelium which
4. Impregnation and embedding composed of typical stratum includes from base to apex,
5. Sectioning and cutting which are stratum basale, stratum spinosum, stratum
granulosum and stratum corneum, respectively illustrated in figures (1a). It show also the second layer of skin, the
dermis below the epidermis compose of dense connective tissue include collagen fibres and rich blood vessels &
nerve supply as showed in figure (1a). There are several hair follicles and sweat glands observed clearly in the
dermis of skin as showed in figure (1c).

Fig. 1: General view of the skin cross section of the control group. Showing the different thickness of the
layer tissue, (epidermis layer), ↔ (dermis),►(hair follicles),→(blood vessel). H & E stain, a (X 40) & c
(X 100)
After skin exposed to laser it shows change in the different layers, but that change never effect on the size of
cells and the wall between cells still apparent. So, these test group shows increase the thickness of the epidermis
layer comparing with different proportion for the control group, this effect clearly appears in the figure (2a). The
first group is illuminate by laser at 2 mW and time 10 minutes, the epidermal thickening on the rate of proliferating
cells of superficial layer, with increase the mitotic activity of cells and large size cells appeared different area of
epidermis; refer to hyperkeratosis of epidermal layer as show in figure (2a, 2b and 2c).

Fig. 2: General view of the skin cross section of the first test group. Showing the different thickness of the
layer tissue, (epidermis layer), ↔ (dermis),►(hair follicles),→(blood vessel). H & E stain, a,b (X 40) & c
(X 100)
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& Development, July 2019, Vol.10, No. 7 511

After reducing the laser power to 1.31 mW and time of exposure 10 minutes (i.e. the second group). The results
illustrate slightly modify on epidermal layer and showing increase the thickness of these layer which noticeably in
figure (3b), stratum corneum revealed a thickening with deattached cells of superficial layer of epidermis as shown
figure (3a) and, a high rate of mitotic activity of epidermal cells at stratum besale as shown figure (3b). Despite of
the thickness increase of the epidermis but, the cells kept the same and get a good adhesion between of them of a
different stratum. The epidermis and dermis appeared in firm attachment of together as showed in figure (3c).

Fig. 3: General view of the skin cross section of the second test group. Showing the different thickness of the
layer tissue, (epidermis layer), ↔ (dermis),►(hair follicles),→(blood vessel). H & E stain, a,b (X 40) & c
(X 100)

To get more information about the time exposure we increase it to 20 minutes with the same power, which is
called the second group. That result shows significantly enhancing of the skin features comparing with that other
groups. However, it shows the slight increases of the epidermis thickness and appearing well architecture of the
skin composition. At present the in figure, (4a) epidermis cells of stratum corneum are more danced. The attaching
between the epidermis and dermis is good and reflect enhancing the rate of mitotic activity of cells in stratum basale
as present in figure (4c).

Fig. 4: General view of the skin cross section of the third test group. Showing the different thickness of the
layer tissue, (epidermis layer), ↔ (dermis), ► (hair follicles), → (blood vessel). H & E stain, a (X 40) & c
(X 100)
When the time of strike increasing to 30 minutes at 1.31 mW or the third group, there is noticeable effect on the
shape of cells and it is found the merging in the cell wall. This effect not good for the tissue cells this merging is the
evidence for abnormal cell growth. Furthermore, the vacoulation in cells in the epidermis is referring to precede the
cells death as showed in figure (5a). De-attach the cells and sub layers of stratum cornum was clear in this group
with irregular increase in thickness of the epidermis and, also found in thickening with spilt part of superficial
layer of corneum. A number of inflammatory cells and leukocytes appear spread in the parenchyma of dermis refer
to damage of blood vessels and inflammation case, showing a decrease of the activities of epidermal, as showed in
figure (5c).

Fig. 4: General view of the skin cross section of the fourth test group. Showing the different thickness of the
layer tissue, (epidermis layer), ↔ (dermis),►(hair follicles),→(blood vessel). H & E stain, a (X 40) & c (X
100)
Discussions cell growth (7, 8), that explain the cells proliferation in
the epidermis of our study, also the He-Ne laser have
One objective of the present study was to assess
a positive on healing hard palate wounds regardless of
the effect of He-Ne laser irradiation on the thickness
the radiation dose. Low power with He-Ne laser was
skin layer of mice therefore we monitor increase
deemed more effective compared to another laser light
of the thickness layers with help of histological
in terms of fibroblast proliferation and collagen fiber
measurements of desire and undesired effect obtained.
density. However, further robust randomized clinical
The results suggest that a low dose of red light (He-
studies are required (9, 10).
Ne laser, 632.8 nm) has significant enhancing of the
skin features comparing with that doesn’t illuminated The significant increasing is found at a dose of 2.548
groups. However, it shows the slightly increases of the J/cm2, however, the dose 4.094 J/cm2 has a little change
epidermis thickness and appearing well architecture of the thickness. On the other hand, it is found in the
of the skin composition specially in figure (1). The inhibition of hair growth due to increase in follicles
attaching between the epidermis and dermis its good with exposure to the He-Ne laser for both doses. That
and reflect enhancing of the rate of mitotic activity of indicates to the enhancement of hair growth related to
cells in stratum basale hair growth in Swiss albino mice skin improving. However, exposure to the He-Ne laser
skin. These results agreement with earlier reports which at a dose of 4.094 J/cm2 caused no significant change (11).
demonstrate that exposure to low-level laser radiation
Effects of low‐level helium‐neon laser radiation
leads to augmentation in proliferative and synthesizing
were
those compared on thickness skin layers of mice
activity of cells (5, 6).
dosages of 6.141 J/cm2 during a 30 min exposure every
Our findings suggest that the He-Ne laser was more day, 4.094 J/cm2 during a 20 min and 2.047 J/cm2 during
effective laser, and significant difference was observed a 10 min exposure. No significant differences in
in terms of the doses within same laser groups and our effect
results were in line with previous studies. That have were observed between laser‐exposed region and control
shown that wavelength is an important factor in exposed. He-Ne laser irradiation of increases certain
controlling
aspects of healing in the early stages, but not to
such
a degree as to be clinically applicable. More detailed power 1.13 mW had a good changes in the architecture
research is indicated to obtain optimal exposure levels of skin. That refer to the optical effect of laser on the
necessary to accelerate effect significantly. These results skin might change the future of dermatology.
to similar to Surinchak et.al when they did vitro study(12).
Conflict of Interest: Nil
The application of the He‐Ne laser 10 mw at
2.548 J intensity for 20 days caused a gradual increase. Source of Funding: Self
Furthermore, microscopic examinations revealed that
Ethical Clearance: Taken
the laser‐irradiated skin changed. The release of stratum
granule
produced from epidermis to hair follicle, and REFERENCE
blood vessel thrombosis of the dermal capillary
plexus(13). A previous study report an increase in cell 1. Ansari MA, Mohajerani E. Mechanisms of
proliferation and collagen production using specific and laser-tissue interaction: optical properties of
somewhat arbitrary laser settings with the helium tissue. Journal of Lasers in Medical Sciences.
neon (He-Ne) and gallium arsenide lasers, but none of 2011;2(3):119.
the available studies address the mechanism, whether 2. Niemz MH. Laser-tissue interactions:
photo thermal, photochemical, or photomechanical, fundamentals and applications: Springer
whereby low power may exerting its effect. Some Science
studies, especially those using He-Ne lasers, report & Business Media; 2013.
improvements in surgical wound healing in a rodent
3. Rinnerthaler M, Streubel MK, Bischof J, Richter
model; however, these results have not been duplicated
K. Skin aging, gene expression and calcium.
in animals such as pigs, which have skin that more
closely resembles that of humans. In humans, beneficial Experimental gerontology. 2015;68:59-65.
effects on superficial wound healing found in small case 4. Suvarna KS, Layton C, Bancroft JD. Bancroft’s
series have not been replicated in larger studies (14). Theory and Practice of Histological Techniques
E-Book: Elsevier Health Sciences; 2018.
Our results showed that a particular laser irradiation
stimulates fibroblast proliferation, without impairing of 5. Yu H-S, Wu C-S, Kao Y-H, Chiou M-H, Yu
layers skin. These results to similar to Pereira et (15). C-L. Helium–neon laser irradiation stimulates
migration and proliferation in melanocytes
The influence of low-intensity polarized visible laser and induces repigmentation in segmental-type
radiation on the acceleration of skin wound healing. vitiligo. Journal of investigative
Low-level laser therapy (LLLT) at adequate wavelength, dermatology.
intensity, and dose can accelerate tissue repair. However, 2003;120(1):56-64.
there is still unclear information about light
characteristics, such as coherence and polarization. Some 6. Karu T, Pyatibrat L, Kalendo G. Biostimulation
studies indicate that linearly polarized light can survive of HeLa cells by low-intensity visible light.
through long propagation distance in biological tissue V. Stimulation of cell proliferationin vitro by
Histological analysis showed that the healing of He− Ne Laser irradiation. Il Nuovo Cimento
irradiated wounds was faster than that of non-irradiated D.
wounds (16). 1987;9(12):1485-94.
7. Moore P, Ridgway TD, Higbee RG, Howard EW,
Conclusion Lucroy MD. Effect of wavelength on low‐
intensity laser irradiation‐stimulated cell
The low power helium–neon laser is representing proliferation in vitro. Lasers in Surgery and
the future of dermatology and the therapeutic application Medicine: The Official Journal of the American
with numerous other applications. The results that found Society for Laser Medicine and Surgery.
indicate skin tissue can enhanced by using low power 2005;36(1):8-12.
laser. The time and power density represent the good
tool to make that enhancing. Histological analysis 8. Carrinho PM, Renno ACM, Koeke P, Salate
displays the results that group illuminated at time 20 ACB, Parizotto NA, Vidal BC. Comparative study
minutes and using
685-nm and 830-nm lasers in the tissue repair of
tenotomized tendons in the mouse. Photomedicine
and Laser Therapy. 2006;24(6):754-8.
9. Fahimipour F, Mahdian M, Houshmand B, Medicine: The Official Journal of the American
Asnaashari M, Sadrabadi AN, Farashah SEN, et Society for Laser Medicine and Surgery.
al. The effect of He-Ne and Ga-Al-As laser light 2000;27(5):420-6.
on the healing of hard palate mucosa of mice.
14. Posten W, Wrone DA, Dover JS, Arndt KA,
Lasers in medical science. 2013;28(1):93-100.
Silapunt S, Alam M. Low‐level laser therapy
10. Evans DH, Abrahamse H. Efficacy of three for wound healing: mechanism and efficacy.
different laser wavelengths for in vitro wound Dermatologic surgery. 2005;31(3):334-40.
healing. Photodermatology, photoimmunology &
15. Ribeiro MS, Da Silva DDFT, De Araújo CEN,
photomedicine. 2008;24(4):199-210.
De Oliveira SF, Pelegrini CMR, Zorn TMT, et
11. Shukla S, Sahu K, Verma Y, Rao K, Dube A, al. Effects of low-intensity polarized visible laser
Gupta P. Effect of helium-neon laser irradiation radiation on skin burns: a light microscopy study.
on hair follicle growth cycle of Swiss albino Journal of clinical laser medicine & surgery.
mice. Skin pharmacology and physiology. 2004;22(1):59-66.
2010;23(2):79-85.
16. Pereira AN, Eduardo CdP, Matson E, Marques
12. Surinchak JS, Alago ML, Bellamy RF, Stuck BE, MM. Effect of low‐power laser irradiation on
Belkin M. Effects of low‐level energy lasers on cell growth and procollagen synthesis of cultured
the healing of full‐thickness skin defects. Lasers fibroblasts. Lasers in Surgery and Medicine: The
in surgery and medicine. 1983;2(3):267-74. Official Journal of the American Society for Laser
13. Kim YG, Pak SC, Lee SR. Hairless mouse Medicine and Surgery. 2002;31(4):263-7.
epidermal antioxidants and lipid peroxidation
assessed by He‐Ne laser. Lasers in Surgery
and
DOI Number: 10.5958/0976-5506.2019.01622.X

The Effect of Electric Stimulation in the Development of the

Explosive and Speeding Ability of the Arms to Achieve the
High Snatch of the Weightlifters Karbala Youth Club

Alaa M. Dhahir
Al-Furat Al-Awsat Technical University, Technical Institute of Karbala,
Iraq

ABSTRACT
In order to reach the rappers to achieve the completion of Snatch, it is necessary to develop muscle strength
and integration with the speed of performance, and to achieve this was developed training Program with
electrical stimulation to see their impact in explosive power and speed-specific power.
The aim of the research is to prepare a training Program for electrical stimulation to develop the explosive
power and the speed of the arms of the weightlifters Karbala youth club, as well as the impact of the
training course on electrical stimulation to develop the explosive power and speed of the arms of the
research sample.
The researcher reached the most important conclusions that the training Program prepared by the researcher
has a positive effect on the development of explosive capability and the speed characteristic and raise the
level of achievement in the high Snatch, with a preference for the training Program electric stimulation
prepared by the researcher, and that elective stimulation sessions lead to the recruitment of all Muscle fibers
to constrict at once and stimulate the backup power of work during performance achievement.

Keywords: electric stimulation, explosive ability, speeding ability and high snatch.
Introduction of muscle strength and rehabilitation of injuries as well
as use in warm up and is widely used in various fields of
Training is a major science that contributes to the
sports and factor medical assistant.1
development of athletic achievement through many
means, tools and procedures that have been adopted in In the sport of weight lifting can be developed
the Program to achieve achievement. The training muscle groups working in lifting through the various
Program depends on the fact of his work on the concerted training methods as well as the use of methods and
efforts in the use of different sciences and employing the techniques to help guide the effort and shortest time to
appropriate tools to reach the desired goal. Trainers to reach the player to achieve the objectives of the training
bring about a kind of change and diversification in the Program. Some researchers used electrical stimulation
vocabulary of the training Program or change the place to contribute to the development of physical abilities,
and form of training In order to increase excitement and but they did not determine the doses according to the
suspense, the use of aids in the development of physical requirements of the muscle and its functional ability
and skill capabilities of athletes and shortening time to rationing doses of stimulation is necessary to guide the
reach the player As well as the ability of these means to work and knowledge of the electrical signal of the
isolate the working muscle alone, which facilitates the contractions caused by the training, which contributes to
process of directing the physical effort to develop the the development of the ability to achieve the
target segment, as the use of electrical stimulation is achievement of the platform and scientific principles.2
useful in the development
The importance of research in the preparation of a
training Program using the electrical stimulation of the
Corresponding Author: muscles working arms to raise the level of achievement
Dr. Alaa M. Dhahir by combining the development of explosive capability
Al-Furat Al-Awsat Technical and increase the speed of performance in the abduction
University, Technical Institute of of young adults.
Karbala, Iraq Email:
[email protected]
516 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 516

Research Methodology and Field Procedures Pretests: The tests were carried out on Monday and
Tuesday, 8-9/10/2018, in Karbala Training Center
Research Methodology: The researcher used the Hall. The tests were carried out. The tests included the
experimental method in two experimental groups with throwing of a medical ball weighing 3 kg, (10) seconds.
both the pre and the post tests. On the second day, the technical tests were carried out,
including the test of the completion of the snatch.
Table 1: Shows the experimental design
Training Program: The training Program was adopted
Experimental by the electrical stimulation of the first experimental
Pretest

Posttest
Groups
Variable group and the training Program without the electrical
Training Program + stimulation of the second experimental group, both of
First experimental which were prepared by the researcher. The quartets
electric stimulation
used the vocabulary of the two methods in the method
Second experimental Training Program
of repetitive training according to the gradual loading of
Community and Sample Search: The research physical and skill exercises. The total number of training
community is represented by Karbala weightlifters (56 units reached (32) training units and was applied during
and 69), which consists of (14) quartets. The researcher the special preparation period.
chose the research society in a deliberate way. They are
For the first experimental group, the training and
the weightlifters of Karbala city in weights (56) kg and electrical stimulation Program was applied in the main
they numbered (6) players quadruple and (69) the study section. It takes 60-65 minutes and gave high-level
sample consisted of (12) quartiles, (85.7%) of the abduction exercises which amounted to (12) exercises
research community, randomly distributed to the first which were divided into weightlifters training units
experimental and experimental groups. Each group during the week. The first part of the main section of
consisted of (6) three-quarters of the weight. The the training unit includes exercises for the technical
first experimental group used the training course with performance of the abduction shield. The second part of
electrical stimulation Prepared by the researcher and the the main section includes physical exercise and
second experimental group has used the same training electrical stimulation. They were coordinated alternately
Program prepared by the researcher without electrical to avoid effort on muscle groups. For the first training
stimulation. using a frequency different from (75-45) Hertz, used
during the first (12) units frequency (45) Hertz time
Search Procedures: Selection of physical and (10) seconds and 10 units of the second frequency
skill
(60) Hertz time (8) seconds and (10) of the last units
capabilities: (75) Hertz time (6) seconds, and the number of
1. Test throwing a ball of medicine from the front of electrical stimulation sessions (32) session.
the chest back weight (3 kg):
Posttests: The tests were carried out on Monday and
2. Withdrawal of the opening of the abduction Tuesday, 10-11/12/2018 at 10:00 am as Monday was
to allocated for physical tests and on Tuesday to test the
stand within (10) seconds and strongly (70%): completion of the snatch.
3. Characterization of the test of completion of
snatch:3
View, Analyze, and Discuss Results

Table 2: Shows mean, standard deviations, (Z) value, and significance of differences between pre and
posttest in physical tests and achievement of the first experimental group

Sl. Pretest Posttest (z) Level of Significance

Tests Units
No. Mean SD Mean SD value significance of differences
Throw a medical ball weighing
1. Meter 7.25 0.326 8.41 0.306 -2.214 0.027 Sig.
(3) kg back
With the opening of the snatch,
2. Second 5.00 0.632 7.50 0.548 -2.251 0.024 Sig.
stand up (10) seconds
3. The completion of the snatch Kg. 69.17 6.178 80.33 5.645 -2.264 0.024 Sig.
* Level of significance (0.05)
Table (2) shows that there is a significant difference the stimulation of electrical exercises were given with
in explosive force of the arms in the test of throwing a (10)
medical ball weighing (3) kg between the pre and post repetitions of one group at high speed and strongly
testing and for the benefit of the post-test. The (70)
researcher attributed the reason to the effectiveness of -90% of the maximum performance. “The use of special
the training Program and electrical stimulation used exercises for the development of speed of lift
within the vocabulary of the training Program, The high- performance contributes to the reduction of performance
speed exercise is similar to the performance of the time through the development of speed strength.”
5
abduction to be the most effective and effective, and the Moreover, electrical stimulation has a positive role,
electrical stimulation has a positive role in the which was used to develop the force explosive with the
development of explosive force “The appropriate duration of the continuation of the current up to 10
frequency to develop muscle strength up to (100) Hertz, seconds, it is “the more exciting continuation of the
and the higher the frequency was the field of training in duration differed different training effects as lead for the
the direction power the duration and duration of the alert alarm for (8-10) again to an increase in the speed of
shall be according to the training objective “.4 muscle contraction arise”. 6

As for the strength characteristic of the speed of the The researcher attributed the reason for this to
arms, there are significant differences between the tests of the integration of physical exercises with electrical
pre and post for the benefit of the post-test, and attributed stimulation, “as it eliminates the rotation of work
the researcher to the effectiveness of the training Program
between the tissues of one muscle and operates the
to develop exercises for this ability and was employed
tissues of the muscle involved in the training once and
with
the adequacy of large and in a single time, Which
increases the efficiency of this electrically operated
muscle “.7
Table 3: Shows mean, standard deviations, Z value, and significance of differences between pre and
posttests in physical tests and achievement of the second experimental group

Sl. Pretest Posttest (z) Level of Significance

Tests Units
No. Mean SD Mean SD value significance of differences
1. Throw a medical ball weighing
Meter 7.16 0.307 7.74 0.359 -2.201 0.028 Sig.
(3) kg back
2. With the opening of the snatch,
Second 5.00 0.894 6.00 1.095 -2.121 0.034 Sig.
stand up (10) seconds
3. The completion of the snatch Kg. 68.00 5.441 70.50 5.577 -2.251 0.024 Sig.
* Level of significance (0.05)
Table (3) shows that there are significant differences between the pre and post tests and for the post-test of
the second experimental group. The researcher attributed this to the use of the training Program prepared by the
researcher where he used training loads in exercises that were repeated according to scientific and training criteria.
The requirements for training this age group that have achieved a comprehensive and balanced development of the
physical attributes under consideration and to ensure their continued development “The use of special exercises
for the purpose of developing the speed of performance of the lift contributes to the reduction of performance time
through the development of speed-specific power”. 8

Table 4: Shows mean, standard deviations, Z value, significance of differences in physical tests,
and achievement of the first experimental and experimental groups in the post-test
Sl. (z) Level of Significance
Tests Units Mean SD
No. value significance of differences
1. Throw a medical ball
Meter 8.076 0.472 -2.722 0.004 Sig.
weighing (3) kg back
2. With the opening of the
Second 6.75 1.138 -2.345 0.026 Sig.
snatch, stand up (10) seconds
3. The completion of the snatch Kg. 75.42 7.416 -2.177 0.026 Sig.
* Level of significance (0.05)
Table (4) shows the post-test of the first stimulation of the muscles working at the high level of
experimental and experimental groups, the mean (8.076) abduction.11 this contributed to the increase of muscle
was at a deviation of (0.472), and the calculated Z value strength, resulting in an integrated development. The
(-2.722) was at a level of significance (0.004), advantage of the use of electrical stimulation is evident
indicating the significance of differences between the in its ability to recruit all muscle fibers to contract at
post-test at the level of significance (0.05) and for once. This is not the case in the case of involuntary
the benefit of the first experimental group. In the constriction where it remains part of the muscle fibers
power differential characteristic of the speed of the did not contract and this part is called the reserve force.12
traction test in the abduction slot to stand within 10
seconds. In the post- test of the first experimental and Conclusions
experimental groups, the arithmetic mean (6.75) has a
deviation of 1.138 and the calculated Z value (-2.345) 1. The training Program prepared by the researcher
(0.026). This indicates the significance of the has a positive effect on the development of
differences between the pre and posttests at the explosive capability and the speed-specific force
significance level (0.05) and for the benefit of the and raising the level of achievement in the high
first experimental group. level of snatch.
2. There is a preference for the electrical stimulation
In the pre-test experiment of the first experimental
training Program prepared by the researcher with
and experimental groups, the mean (75.42) was a linear
the positive effect in the development of explosive
deviation of (7.416) and the calculated Z value (-2.177)
force and the strength of speed and raise the level
at the level of significance (0.026). This indicates the
of achievement in the high snatch.
significance of the differences between the two tests
(0.05) and for the first experimental group. Table (4) 3. The regulated diversity in the values of the
shows a significant difference in the explosive force of electrical stimulation frequencies used by the
the test arms and for the benefit of the first experimental researcher contributes to the development of the
group. The researcher attributed the reason to the special muscle strength of the muscle groups
effectiveness of the training Program and the electric working at the height of the abduction.
stimulation directed towards the target muscle groups. 4. Electrical stimulation sessions help to recruit all
The appropriate frequency for the development of muscle fibers to constrict at once and stimulate
muscle strength is up to (100) the highest frequency the back-up force to work during performance to
was the field of training in the direction of the explosive achieve achievement.
force and the duration of the alert will be according to
the training target “.9 Ethical Clearance: Taken from Technical Institute
of
As for the strength characteristic of the speed of the Karbala, Iraq.
arms, there are significant differences in the post-test
and for the benefit of the first experimental group and Source of Funding: Self
attributed the researcher to the reason for the increase
Conflict of Interest: None
in the components of the training load of the size of the
training increases the frequency of the hands to (10)
repetitions of exercises used in addition to the electrical REFERENCES
stimulation has a positive role, “The different duration of 1. Ali S. J.: tests, measurement and statistics in the
the continuation of the stimulant arise different training field of sports, Edit.1, Qadisiyah, University Press
effects as the duration of the alarm for (8 - 10) seconds Qadisiyah, 2004, p. 95.
to increase the speed of contraction of the muscle”. 10 As
for the variable of completion of the snatch, there are 2. Omar K. A.: standardization of training loads
significant differences in the post-test and for the benefit in accordance with the method of hierarchical,
of the first experimental group. The researcher attributed flat and italic and its impact in some forms of
the reason to the effectiveness of the training Program muscle strength and achievement of the height of
by integrating the physical exercises with the the nit for ages (18-19) years, Master,
electrical Baghdad
University, Faculty of Physical Education and abilities and achievement of young adults, doctoral
Sports Sciences, 2014, p.68 thesis, University of Diyala, Faculty of Physical
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Weightlifting Regulations 2001-2004, International 9. Abu El-Ela A. A.and Ahmed N.: physiological
Weightlifting Federation, 2004, p. 69. physiology, Cairo, Dar Al-Fikr Al-Arabi, 2003, p.
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medicine, Mosby college publishing, 1999, p 20- 21. 10. Alsayigh HA, Athab NA, Firas M. Journal
5. AbdelMoneim H. S.: The effectiveness of some of Global Pharma Technology The Study of
special exercises to develop the speed of the Electrical Activity of the Triceps Brachia Muscle
motor performance of the young players in high according to the Chemical Changes of Water Loss
snatch, Master Thesis, Faculty of Physical during Spike in Volleyball. 2017;57–62.
Education and Sports Sciences, Diyala University, 11. Al-mashhadi RAA. The Impact of the Plan and
2005, p. 47. PDEODE Strategies in Developing Awareness of
6. Fawzi A.: Sports Medicine and Fitness, Edit.1, Cognitive Processes and Reducing Psychological
Lebanon Dar al-Ulum Arab, 2000, p. 43. Pollution Among Students of the Faculty
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7. Kadri B.: Muscle Training and Electrical Alert, 2018;928–35.
Regional Development Center of the International
Amateur Athletics Federation, 1996, p. 12. Alsayigh HA, Athab NA. The Study of Rectus
Femoris Activity after Knee Joint Rehabilitation.
8. Omar S. A.: Effect of training on the five areas of 2016;9(9):360–5.
stress in some biochemical variables and
special
DOI Number: 10.5958/0976-5506.2019.01623.1

Monte Carlo Simulation to Estimate the Male and Female

Effective Dose due to Radon Exposure in Al-Najaf

Mokhalad Ali Zbalh1, Hussien Abid Ali Bakir2, Ali Abid Abojassim2, Adhraa Baqir Hassan3
1
Department of Genetic Engineering, Collage of Biotechnology, Al-Qasim Green University, Babylon,
Iraq;
2
Department of Physics, Department of Biology, Faculty of Science, University of Kufa, Al-Najaf,
3

Iraq

ABSTRACT
In this article, the concentrations of radon gas (222Rn) in some houses were measured at 10 sites in Al- Najaf
city, using RAD-7 radon monitoring system. The effective doses for all samples were estimated using
Monte Carlo method. The Visual Monte Carlo code was used to simulate the transport of the radiation as
emitted from the 222Rn through the human voxel model. Room geometry of 3×3×4 m3 was designed to
estimate the people radiation dose due to the exposure to the indoor radon. The latter doses were estimated
for each of male and female people individually. It is found that the radon concentrations varied from (8.75
± 1.1 Bq/ m3) to (32.32 ± 4.0 Bq/m3) with an average (20.57 ± 2.90 Bq/m3). The resulted data of the Monte
Carlo calculations for male reveal that the effective dose was ranged from 2.91E-05 to 1.07E-04 μSv/h
while the female effective dose was noticed to range from 2.87875E-05 to 1.06333 E-04 μSv/h.

Keyword: 222Rn, Monte Carlo, effective dose, Al- Najaf city and RAD-7.

Introduction these cracks into home. In this context, at some areas of

the country the amount of uranium and radium in rocks
Radon gas is a natural radioactive source and is
of different kinds, such as phosphate rock or granite,
chemically considered as an inert element. It originates
is high. In areas like these the radon levels in outdoor
from the natural decay of uranium 238 series, with
air is generally expected to be high(3). The radon gas
atomic number 86 and mass number 222(1). The major
enters the houses from the ground via cracks present in
contribution of radon exposure is attributed to indoor
concrete of the floors and walls, then through the gaps
or household air(2). In this regards, many houses and
between floor and slab, around drains and pipes, and
buildings are built on top of radon emitting rocks. It
small pores of hollow-block walls. It is important to
should be noted that radon daughters are likely to attach
mention that radon levels usually high in places such as
to dust which would result in that people are exposed to
basements, cellars and ground floors. Based on certain
them via breathing. However, the radon level in outdoor
factors, the concentration of radon in indoors changes
air is, to large extent, low at about 0.003 to 2.6
considerably throughout the time of the year, from day
picocuries/ liter of air. When considering the indoor
to day, and from hour to hour(4,5). As reported in many
exposure, such that at homes, schools, or offices
countries, the radon is taking the second order of being
buildings, the levels of radon and its daughters are
the most important cause of lung cancer after smoking(6).
generally higher than that of outdoor levels. Cracks
Nevertheless, relevant studies in Europe, North America
exist in the foundation or basement of the homes can
and China have also confirmed that even at lower
increase the level of the radon. This happens when
concentrations of radon – such as those live in
the radon gas move through
homes
– also include health risks and contribute markedly to
Corresponding Author: the occurrence of lung cancers worldwide(7,8). It has been
Ali Abid Abojassim reported that probability of lung cancer incidence can
Department of Physics, Faculty of Science, increases by 16% per 100 Bq/m 3 of radon concentration
University of Kufa, Al-Najaf, Iraq increment. In this regards, the dose-response relation
Email: [email protected] appears to be linear, this means that the lung cancer risk
521 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 521

increases proportionally with increasing radon exposure. help in observing the variations occur within the radon
The level of the environmental radon is a function of concentration levels during the measurement period.
time and climatic conditions. So, on order to monitor the This might be effective, in turn; in the case that one
radon level, active and passive techniques can be used. can check the factors that impacting the radon levels
Active method often used for short-term measurements throughout time. To illustrate, these factors may include
of radon. By contrast, passive method could be suitable temperature variation, wind speed, humidity (relative).
for the assessment of radon exposure over long period of This could give an insight into movements of the air
time. This enables it to be used for large-scale surveys at inside a room(13). The RAD-7 includes an internal
a low cost(9). In active measurement, in general, radon standard sample cell at around 0.7 liter and has a
and its decay products are brought either into the hemispherical shape as can be observed in Figure (1).
vicinity of a detector or into a collector device via forced The inner side of the hemisphere is coated with an
pumping, while in passive measurements, radon and its electrical conductor that can be changed, with a high
decay products are collected through their natural power supply, to a potential difference range of about
diffusion (or permeation) into the device, containing a 2000-2500 Volts relative to the detector. This in turn
detector. The terms active and passive are also used to creates an electrical field across the cell. The latter
differentiate those radiation detectors that operate with electric field drives the positively charged particles into
and without power supply. However, estimation of the the detector in the periodic-fill cell.
amount of dose received by tissues/organs of the body
that exposed to radiation source in an environmental
medium is an extremely difficult computational task(10).
Therefore, Visual Monte Carlo (VMC) is
computerized software that simulates the human body
irradiation by an external source of radiation. It uses a
voxel phantom designed at Yale University and the
Monte Carlo method to simulate the emission of
photons by a point, ground, cloud source as well as
X-ray source. It therefore simulates the transportation
of the photons through the phantom of the human body
and estimates the dose to all body regions(11). Fig. 1: Schematic diagram of the RAD-7 detector(14)
Consequently, this permits the estimation of the
effective dose. The aim of the present work is to The method which was adopted to collect the
measure the radon concentrations in some houses of Al- samples can be described as follows: Four samples for
Najaf area. Also by using Monte Carlo method the the house air were taken from each region. The number
estimates for the effective dose can be provided for both of air samples that considered in this work was forty.
male and female voxel phantoms/models. The sniff mode and circle time was set at 1 hour in
accordance with running time of each path of the valve.
In order to investigate the amount of radon released
Materials and Method
from the sample to air, the samples were enclosed into
Najaf city situated between coordinates of latitudes a column, and an airborne radon/thoron was measured
of 32°21ƍ N and 29°50ƍ N, coordinates of longitudes of with a continuous monitor of electrostatic type (RAD-7,
44°44ƍ E and 42°50ƍ E with a total area of 28,824 km2 Durridge Company, and USA). The flow rate of the air
(6.6% of Iraq whole area)(12). Al-Najaf city, considering was 0.7 L min-1. The air of the room was drawn from
the administrative side, includes three qadhaas the, and the radon generated in the air flow system was
(administrative units consisting of the governorate, Al- measured using the RAD-7 device.
Manatheria, Al-Kufa and Al-Najaf Qadhaas). In the
The concentration of radon in the inside cell of
current study, ten sites were selected as fair distribution
RAD7 is calculated by the following equation(15):
in Al-Najaf city.

The RAD-7 is a device that provides a real-time

dU (t )
= lU(t) …1
and continuous monitoring for radon. The latter dt
would
dU Po (t ) was later extended to include alpha particle, electron and
= l U(t) – l U (t) …2
po po po proton transport through a specified voxel structure. To
dt investigate the validity of this software, it has previously
where U(t) represents the concentration of radon in been benchmarked via comparisons with many other
the RAD7 internal cell, l is the radon decay models and Monte Carlo software(17).The results of
constant,
UPo(t) is a concentration of 218Po, and lpo is decay these validation attempts show a good agreement for the
constant of 218Po and equals to 0.0037s−1. effective dose due to cloud immersion obtained using
VMC and Federal Guidance Report No.12. In this paper,
Once the pumping time has elapsed, the
the program provides coefficients that based on the
concentration of radon in the inside cell of RAD7 equals Monte Carlo simulation to calculate both the organ and
that of the environment
o
C . Equation 2 can be rewritten effective dose as a result of radiation exposure.
as
dU Po (t )
= l U – lpoUpo(t) …3
dt po Results and Discussion
o
The initial condition is
The resulted data concerning the level of radon
Upo(0) = 0 …4 concentrations in houses air and for the 10 sires at Al-
Najaf are presented in Table (1). According to Table (1),
The solution of Eq. (4) is it can be seen that radon concentrations were varied
from (8.75 ± 1.1 Bq/m3) in location (N10 sample)
Upo(t) = Uo(1 – e–lpot) …5 to (32.32
± 4.0 Bq/m3) in location (N1 sample) with an average
When the time is much longer than that of the half-
value (20.57 ± 2.90 Bq/m3). The variations of radon
life of 218Po, Equation 5 then can be rewritten as (3).
concentrations which were seen among different regions
Upo(t) = Uo …6 can be caused by a number of factors. These include
things like the geological structure of the sites, different
The concentration of radon can be calculated using kinds of building materials that used to construct
Equation 6, and this is the measurement principle of houses, the heating systems together with ventilation
RAD-7. The RAD-7 utilizes a high electric field over a level, the aging effect on the building and the social
silicon semiconductor at a ground potential to catch the habits of the dwellers. The maximum value of 222Rn
concentrations in present study is which is much lower
heavy charged of the polonium daughters, 218+Po (t1/2 = than the recommended ICRP indoor of (200-400) Bq/
3.1 min; Ea = 6.00 MeV) and Po (t1/2 = 164 µs; Ea = m3(18). Comparing these results with those of the Arabic
7.67 MeV), which are estimated in sample as a measure countries it was found that the range of average
radon
of 222Rn activity concentration., the RAD7 prints out
a concentration in Jordan (west of Iraq) building measured
is (9.95 – 68.15) Bq/m3(19) and in Egypt particularly
summary of the average radon reading at the end of each in
some region, the average radon concentration in air
run (about 30 min for each run). The time required for of
the process of collecting and analyzing the sample is buildings was reported to be about 79.505 Bq/m3 in
corrected using equation (3): range from (38.62-120.39)Bq/m3(20).

U = Uoe–lt …7
Table 1: Results of Radon222Concentrations
Rn Concentrations
where U is the recorded concentration, Uo calculates Location
No. Study Site
primary concentration next to the decay corrections and Sample Mean ± Standard
Error
t
is the elapsed time until collection in day unit, λ = 0.181, 1. Missan N1 32.32 4.0
t1/2= 3.83 days. 2. Asskry Kufa N2 28.62 3.6
3. Mutnabi N3 27.95 3.5
VMC Validation: This VMC program was written
4. Jmohria N4 11.78 1.5
in the Instituto de Radioprotecão e Dosimetria for
simulating the radiation transport via specific voxel 5. Tmoz N5 17.17 2.1
model. Basically, this program was written using visual 6. Srrai N6 28.28 3.5
7. Addalh N7 9.09 1.1
basic, and can be applied to both internal and external
dose calculations resulted from photons(16). The program
Conted… According to the above Tables (2 and 3), it is clear
that for male the highest effective dose was noticed to be
8. Saad N8 14.48 1.8
at Missan site with a value of 1.07E-04 μSv/h whereas
Asskry
9. N9 27.27 3.4 the lowest was found to be at Milad site with an
Najaf
effective dose of 2.91E-05 μSv/h. By contrast, when
10. Milad N10 8.75 1.1
considering the female effective dose, the highest was
Average ± S.E 20.57 ± 2.90 0.000106333 at Miasan site and the lowest was at Milad
Effective Dose: The results of the Monte Calro with an effective dose of 2.87875E-05 μSv/h. The
simulation which was conducted for the room geometry reasons behind the above fluctuations in the value of
that mentioned above to calculate the effective dose dose can be attributed to the level of radon detected in
for human exposed to radon at indoor are presented these sites (see Table 1). Also, it should be mentioned
in the Table 2 and 3 for each of the male and female that Missan site as a one of the new neighborhoods in
respectively. Najaf city is undergoing a marked wave and building
using different materials that could arise the level of
radon. The rest of the sites reveal different levels of
Table 2: the male effective dose estimated at room
radon and therefore exhibit different radiation absorbed
geometry of 3*3*4 m3
dose.
Location Male effective
Bq/m 3
Sample dose (μSv/h) Conclusions
N1 32.32 1.07E-04
N2 28.26 9.38E-05 According the results of the current work, the
following conclusions can attained: all the findings of
N3 27.95 9.28E-05
radon concentrations were obtained in this study were
N4 11.78 3.91E-05
less than the allowed level. The highest people effective
N5 17.17 5.70E-05 dose whether for male or female was found to be at
N6 28.28 9.39E-05 Missan Neighborhood of Al Najaf city.
N7 9.09 3.02E-05
N8 14.48 4.81E-05 Conflict of Interest: There are no conflict interest.
N9 27.27 9.05E-05 Source of Funding: The authors declare that they have
N10 8.75 2.91E-05 no competing interests.

Ethical Clearance: All authors are in accordance with

Table 3: The female effective dose estimated at room
the ethical standards of the responsible committee on
geometry of 3*3*4 m3
human experimentation (institutional and national) and
Female with the Helsinki Declaration of 1975, as revised in
Location
Bq/m 3
effective dose 2000 (5).
Sample
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DOI Number: 10.5958/0976-5506.2019.01624.3

Impact of Material of Water Storage Tanks on Bacterial

Quality in Shualat Al-Sadrain City in Baghdad

Amel Mustafa Kamil1, Khadeja Shaaban Hasan1, Sajad Mahdi Hasan1

1
Department of Community Health, College of Health and Medical Technics, MiddleTechnical
University, Baghdad, Iraq

ABSTRACT
The most important reason for storage water in special tanks in the buildings and houses is an insufficient
amount of water. These tanks enhance the causative agent of water contamination through several aspects
like its shape, size, color, position, cleaning….etc., therefore,the current study was aimed to investigate
the effect of tanks material on the microbial quality of water in Shualat Al- Sadrain region in Baghdad city
through four summer months Jun, July, August, and Septembe 2017.
120 water samples were collected from 40 tanks of drinking water, three samples were taken from each
tank at the same time. These tanks divided into two groups 20 tanks were made from galvanized iron,
and the rest 20 tanks were made from plastic. The temperatures of water were recorded at the time of
collection. These entire water samples were undertaken to microbial test in the laboratory of a hospital of
Baghdad in the medical city in Baghdad. The results show significant differences in bacterial growth
between two types of tanks. Enterobacter contamination involves E. Coli, Fecal E. Coli, Klebsiella and
Proteus among plastic tanks. In the conclusion: A lot of factors affect water contamination in tanks, whereas
the most important one is Iraq climate, which leads to conclude that the galvanized iron tank is suitable and
has fewer disadvantages than a plastic one in Iraq and hot areas.

Keywords: water storage tanks, drinking water, microbial quality, plastic tank, iron
tank
Introduction sedimentation (7) While, the poor maintenance of aging
Aluminum tanks will affect the nature of stored drinking
Water pollution was definedas theaddition of an
water(8). Beside organic materials sedimentation may
article or energy to an aquarium environment as a result
precipitate to the safe water from plastic tanks (9, 10) in
of human activity or natural sources which lead to
addition to spread a lot of kinds of bacteria on their
negative effects on human health and other organisms.
surface, causing water contamination(11).
(1)
70% of fresh water on the ground is altered to being
ineligible for consuming (2), whereas more than 1 billion
of the world population inhabit in a poverty area suffer Material and Method
from this problem(3), 80% of diseases are waterborne
The study was conducted between 1 June to 30
diseases in the different areas of the world as WHO
September 2017, which considered summer months in
reported where poor sanitation and unhygienic treatment
Iraq characterized by high temperature. The minimum
of drinking water cause 3.1% of death around the world
temperature ranging from 27- 34c (2.93- 6.80 F), while
(4, 5)
, One of the most challenges in the world is providing
the maximum temperature ranging 43- 47c (116.6-
safe water, particularly in the countries which suffer
107.6 F). However, sometimes reaches to 50 co or
from a shortage in their water stored. Thusled to use
more, according to the first report of the ministry of
tanks in different capacities to keep safe water for daily
environment in Iraq.
usage, which varies in their types, sizes, shapes, and
colors. As well as theyvary in their position. Numerous Area of Study: The investigated area located in the
factors, physical, chemical and biological rise water west of the capital of Iraq (Baghdad), which occupies
contamination in these tanks(6) that cause a different the northwest district of it. It is known as Shualat Al
health problem. For instance the galvanized tanks cause Sadrain. It is the second highly populated region in
Zink and Cadmium
526 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 526

Baghdad, where almost of them are limited income. analysis in the laboratory (the total samples number 40
This area provides by dinking water from Al- Hussain samples were undertaken to microbial analysis). 10 fold
desalination plant, where chlorine use as disinfectant. dilution of the samples were conducted, and utilized
for culturing as the following: 0.1 ml of each dilution
Water Sampling: Sampling was done at 3 a m from 40
were cultured in the Nutrient, MacConkey, SS agar for
roof tanks, by using disposable sterile hand gloves. 20
bacteriological identification and Sabharoud dextrose
of those tanks were galvanized iron (cubic shape) water
agar for fungi identification. All plates were aerobically
storage tanks and 20 were plastic tanks (halve cylinder
incubated 24 hrs at 37co and inspected for the microbial
shape, white in color), both type tanks were 1000 litters
growth. Gram-positive and negative bacteria were
in its capacity. Three samples were taken from each tank
identified according to the standard microbiological
by sterilizing bottles of 500 ml and had been transported
procedure(13) Bacterial colonies were differentiated in
cooled after adding of 1ml of 10% sterile sodium
compliance with the colonies characteristics. A series of
thiosulfate (Na2S2O3) to inhibit the action of chlorine.
biochemical tests were carried out to positive cultures.
Measurement of Temperature: Temperature The bacterial colony counter was used to get the number
measurement was carried out at the site of sample of bacteria/ml of water.
collection using a mobile thermometer. This was done
by dipping the thermometer into the sample and Statistical Analysis
recording the stable reading.
The Statistical Analysis System- SAS (2012)
Bacteriological Analysis: This analysis had done program(14) was used to effect of different factors in study
according to (12) on the Baghdad hospital laboratory in parameters. The Chi-square test was used to significant
the medical city in Baghdad. All three samples per one compare between percentage and T-Test was used to
tank were pooled together to produce one sample significant compare between means in this study
for

Results

The results of the current study as shown in the following tables

Table 1: Effect of tanks type in water temperature

Mean ± SE of temperature (C)
Type of Tanks
June July August September
Plastic 37.58 ± 0.20 41.83 ± 0.61 42.24 ± 0.19 37.58 ± 0.20
Iron 40.75 ± 0.47 51.30 ± 0.53 51.75 ± 0.44 39.00 ± 0.42
T-Test 2.047 ** 3.848 ** 2.175 ** 1.991 **
** (P<0.01).

This table shows significant differences (P<0.01) in the effect of type of tanks on the temperature. The high level
of temperature in the iron tanks in the four observation months

(40.75, 51.30, 51.75 and 39.00) respectively, while the low level in the plastic one (37.58, 41.83, 42.24, 37.58)
for the four months (June, July, August and September) respectively.

Table 2: Effect of tanks type in Bacterial count

Mean ± SE of Bacterial count (x 105)
Type of Tanks
June July August September
Plastic 3.71 ± 2.40 0.00 ± 0.00 0.00 ± 0.00 5.11 ± 3.35
Iron 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 0.0041 ± 0.002
T-Test 1.918 ** 0.00 NS 0.00 NS 1.551 **
** (P<0.01).
The table shows the effects of tanks material made on the type of bacterial count during four months. There are
significant differences (P<0.01) between the two tanks type in the presences of bacterial count. The superiority of
bacterial count among plastic tanks in June and September (3.71, 5.11) respectively, while the results of July and
August were marked by no significant differences between the two types.

Table 3: Distribution of Bacterial growth type with difference of tanks//June

Plastic Iron
Bacteria Chi-Square (χ2)
No % No %
Proteus 2 40.00 0 0.00 10.58 **
E. Coli 2 40.00 0 0.00 10.58 **
Fecal enter Coli 1 20.00 0 0.00 7.94 **
Total 5 100 0 0.00 15.00 **
** (P<0.01).

The table shows different types of bacterial growth in the plastic tanks which marked by Proteus, E. Coli,
Fecal enter Coli (40.00, 40.00, 20.00) respectively during June. While there is no bacterial growth in the iron tanks.
Therefor there are significant differences (P<0.01) between the two types.

Table 4: Distribution of Bacterial growth type with difference of Tanks//September

Plastic Iron
Bacteria Chi-Square (χ2)
No % No %
Klbsella 2 40.00 0 0.00 10.58 **
Proteus 2 40.00 0 0.00 10.58 **
E. Coli 1 20.00 2 10.0 13.27 **
Total 5 71.43% 2 28.57% 11.46 **
** (P<0.01).
The table shows different types of bacterial growth when it has 3-10 and more than 10 cell/100ml of water
in the plastic tanks which marked by Klebsiella, Proteus respectively (20). The results show other observation 40%
and E. Coli (40.00, 40.00, 20.00) respectively during Klebsiala and 40% proteus which agree with (21,17). Also,
June. While 10.0 of the iron tanks contains E. Coli. 20% of isolates were fecal E. coli that agrees with (22,23),
Therefor there are significant differences (P<0.01) but disagreewith(24).This type of water, inadequate for
between the two types. drinking (25), where the recommended ratio of WHO is0
cfu/100 ml (19).The aged and leakage of pipe distribution
Discussion system in addition to infiltration of sewage line access
into the pipe network of DW were the reasons of these
The results demonstrate that the abundant results (26, 27,18).Solid materials loaded water could be
contamination of water is Enterobacter genus which deposited within pipes due to low level of providing
agree with (15, 16), particularly E. Cole, that agree with water in summer season result in accumulation and
several studies (17, 18). The existence of minimum level proliferation of microorganisms depending on their
of microbial growth in the drinking water swerves from oligotrophic adaptation through their coexist in the
WHO 2006 permission (19)however, some health agency drinking water (less than 2 mg of organic matter per liter
classifies drinking water to four classes according to the of drinking water in many cases) which will access the
presence of coliform bacteria: very acceptable water tanks through power of water plumping machine, which
when it has 1 or less E. coli/100 ml of water. While uses in tanks filling throughout a day, the usage of
acceptable water if it has 1-2 cell/100 ml of water, plumping machine increases the corrosion and erosion
whereas the suspected water and unacceptable water of pipes materialto be focus for saprophytic and
opportunistic microbial
attachment and proliferation(28). Materials of pipeline, 2. Anil K Dwivedi. Research in water pollution: A
whatever it made plastic or metal are corroded and stay review, International Research Journal of Natural
spacious colonized by microorganisms through their and Applied Sciences.2017: 4, (1).
physical nature(29, 30).
3. World Bank. World Development Report 2010:
The significant differences in the temperature Development and Climate. 2009
between the two types explain the ability of bacterial
4. Khan N, Hussain ST, Saboor A, et al.
growth in the plastic than iron tanks, since the mean Physiochemical investigation of the drinking
temperature of plastic tanks 37.58c in June and water sources from Mardan, Khyber
September which considers the ideal temperature for Pakhtunkhwa, Pakistan. International journal
bacterial growth (31), while July and August characterized of physical sciences.2013: 8(33):1661-71.
by high temperature (the hottest months on record in
Iraq) that prevents bacterial growth in the two tanks 5. Pawari MJ, Gawande S. Ground water
pollution
types, while the highly corrosion of iron promotes
& its consequence. International journal of
bacterial colonization(32) However, another contributing
engineering research and general science. 2015:
factor cooperates water tanks contamination is overnight
3(4):773-76. 6. J
stagnated water in the pipes (the residents explain) plus
plumping usage on the day will aggravate microbial 6. Wright J, Gundry S and Conroy R. Household
activity(33, 34).This factor is critically important where drinking water in developing countries:
the stagnation of water enhances microbial metabolism a systematic review of microbiological
and increase their concentration in the winter months(35, contamination between source and point-of-use.
36).
The current study shows only 10% of the iron tanks Tropical Medicine and International Health. 2004:
(open lid) had E. coli contamination which access 9 (1), 106-117
through birds feces or soil particles. (37)It should be 7. World Health Organization. Zinc in drinking-
noted that all tanks have not washedsince 12-15 years, water. Background document for development of
thusincreased the opportunity for growth of bacteria. WHO Guidelines for Drinking-water Quality. 2003
Studies reported three times cleaning annually decrease
8. Al-Azaw MGh, Al-Azawi SA and Al-Obaidi
the level of E.coli in the water stored comparing with
RMS. Study of Aluminum concentration levels
less frequent cleaning(38).
in Tigris river, drinking water treatment plants
and supply network in Nineveh Governorate, AL
Conclusions Rafdain Engineering Journal. 2010: 18, 13-25.
The most important factor has revealed in this study 9. Brick T, Primrose B, Chandrasekhar R, Roy S,
is the high temperature of Iraq, which plays a significant Muliyil J, and Kang G. Water contamination in
role in determining the kind of tanks material that should urban south India: household storage practices
use in Iraq for stored drinking water. The iron tanks are and their implications for water safety and enteric
less bacterial growth comparing with plastic tanks in infections. International Journal of Hygiene and
summer months. Environmental Health. 2004:207 (5), 473-480.

Conflict of Interest: There is no conflict of interest. 10. Nath KJ, Bloomfield SF and Jones M. Household
water storage, handling and point of use
Source of Funding: Self treatment. A review commissioned by IFH, 2006:
Accessed Online: http://www.ifh-
Ethical Clearance: Not required
homehygiene.org
11. Evison, L., and Sunna, N. Microbial re-growth
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DOI Number: 10.5958/0976-5506.2019.01625.5

A Descriptive Study on Pulmonary Tuberculosis in Salahaddin

Governorate, Iraq

Hasan Ismail Sultan1, Noor Alhudaa Sadoon Khalaf2

1
F.I.C.M.S, Department of Medicine, College of Medicine, Tikrit University-Tikrit, Iraq; 2MB. CH. B.
Salahaddin General Hospital-Tikrit, Iraq

ABSTRACT
Background: Tuberculosis (TB) remains a leading cause of death in the world. Iraq is considered to be a
middle burden country with TB.
Objective: is to evaluate patients with pulmonary tuberculosis in Salahaddin Governorate.
Patients and Method: the study included 140 patients with pulmonary tuberculosis, who attended chest
diseases clinic in Tikrit during the period from May to August 2018. Pulmonary TB treatment outcomes
were evaluated according to WHO definitions as new case, cured, relapsed, failed and defaulted.
Results: A total 140 pulmonary TB patients were included in this study with mean age of them was 42.7 ±
15.7 years. The males represented 51% of patients while the females were 49% of patients. Most of patients
in this study were beyond primary school education, low income and displaced families represented
as
88.6%, 90.7% and 82.1% respectively. Regarding outcome of treatment with anti TB; 78.6% of patients
were cured, 7.1% of patients were relapsed, while defaulted and failed patients presented in 2.9% of
patients for each one of them.
Conclusion: Pulmonary tuberculosis is still growing problem in this locality. It is common among
low
education, low income and displaced patients.
Keywords: pulmonary tuberculosis, Salahaddin, displaced patients, TB outcome.

Introduction Mediterranean region among countries with TB burden

size. According to WHO report 2015, the estimated
Tuberculosis (TB) remains a leading cause of death
incidence of TB in Iraq is 45/100000 population,
in the world, nearly one third of the global population is
while the prevalence is 74/100000.(3,4,5) Moreover, after
infected with Mycobacterium tuberculosis and at risk of
the 2003 war with deterioration of security and living
developing the disease.(1) Furthermore, more than 90% of
condition, the infrastructure and health services to
global TB patients and deaths present in the developing
effectively provide TB care were seriously damaged.(2,3,5)
countries, where 75% of patients are in the most
economically productive age group (15-54 years). (2,3) The objectives of this study are to evaluate patients
with pulmonary tuberculosis and to assess their
Iraq has an estimated population of 33 million
adherence to treatment in Salahaddin Governorate.
and is considered to be a middle burden country with
TB, and occupies rank 108 globally and 7 in
eastern Patients and Method

A cross sectional study, including 140 patients with

pulmonary tuberculosis, who attended outpatient clinic
Corresponding Author: of chest diseases in Salahaddin Governorate in Tikrit,
Hasan Ismail Sultan during the period from May to August 2018. Patients
F.I.C.M.S, Department of Medicine, were selected irrespective of the duration of disease and
College of Medicine, Tikrit University-Tikrit, Iraq therapeutic status.
Email: [email protected]
532 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 532

The diagnosis was made according to WHO criteria: or more and return to the health services with
A patient was considered as pulmonary TB case if he/ features of active pulmonary TB. (7,8,9)
she has symptoms for 3 weeks or more with one of the
following: (6,7,8) The study was accepted by ethical committee of
College of Medicine- Tikrit University and Salahaddin
z At least 2 direct smears positive sputum. directorate of health. All patients were instructed about
z One direct smear positive sputum and positive the study and their agreements were taken.
CXR finding.
Statistical Analysis: The collected data was statistically
z 3 consecutive negative sputum smears but strong analyzed using statistical package for social science
evidence of pulmonary TB by CXR and clinical (SPSS) version 18. Chi (χ2) square test and t- test were
features.(6,7,8) used to compare the statistical difference among of
variables. P value of ≤ 0.05 was regarded as statistically
Treatment Outcome: The following definitions were
significant.
obtained from WHO reports to explain treatment
outcome: (6,7,8)
Results
z New case: Patient who has never had treatment for
tuberculosis.(12, 13) The general demographic characteristics of studied
patients: The demographic features of present study
z Cure: Patient who completed treatment and
were shows in table 1. A total 140 pulmonary TB
have negative sputum smear in the last month of
patients with mean age of them was 42.7 ± 15.7 years
treatment. (6,7,8)
were included in this study. The males were 71 (51%)
z Relapse: Patient who has been cured from patients, while the females represented 69 (49%)
pulmonary TB previously, and now diagnosed with patients without significant difference between them.
an active disease. (6,7,8) There was significant difference between males and
z Failure: Patient who while on treatment remained females regarding body mass index (BMI), educational
or become again smear positive 5 months after level and economic state. Most of patients in this study
commencing treatment. (7,8,9) were beyond primary school education, low income
and displaced families represented as 88.6%, 90.7%
z Defaulter: patient whose treatment was interrupted and 82.1% respectively. Moreover family history of
or stopped as soon as he feel better for two months pulmonary TB present in 13% of patients.

Table 1: General demographic characteristic of studied patients

Males Females Total
Variables P value
No. % No. % No. %
Number % 71 51% 69 49% 140 100% >0.05 NS
Age (years) mean ± SD 40.97 ± 14.2 44.4 ± 17.1 42.7 ± 15.7 >0.05 NS
BMI (Kg/m2) mean ± SD 22.2 ± 2.1 20.5 ± 2.3 21.4 ± 2.4 <0.05 S
Illiterate 1 1.4% 1 1.4% 2 1.4%
Educational level Primary 56 78.9% 68 98.6% 124 88.6% <0.05 S
Secondary 14 19.7% 0 0% 14 10%
Low 59 83.1% 68 98.6% 127 90.7%
Income <0.05 S
Good 12 16.9% 1 1.4% 13 9.3%
History of Yes 58 81.6% 57 82.6% 115 82.1%
<0.05 S
displacement No 13 18.3% 12 17.3% 25 17.9%
Family history of Yes 7 10% 11 16% 18 13%
>0.05 NS
TB No 64 90% 58 84% 122 87%
Symptoms of Pulmonary TB in Studied Patients: Moreover, this study showed that the most common presenting
symptoms were cough and sputum present in 138 (96.6%) patients, followed by fever 136 (97.1%) patients, sweating
125 (89.3%) patients, anorexia 93 (66.4%) patients, and weight loss 72 (51.4%) patients, as shown in table 2.

Table 2: Frequency of symptoms of pulmonary TB in studied patients

Frequency Percent
Cough 138 98.6%
Sputum 138 98.6%
Fever 136 97.1%
Sweating 125 89.3%
Anorexia 93 66.4%
Weight loss 72 51.4%
Hemoptysis 46 32.9%
Dyspnea 29 20.7%
Pleuritic chest pain 11 7.9%
Others (joints pain) 2 1.4%

Chest X ray (CXR) Findings of Pulmonary TB in Studied Patients: Regarding chest X ray (CXR) findings,
most of patients had nonhomogeneous opacities presented in 70 (50%) patients followed by cavity lesions in 30
(21.4%) patients, pleural effusion in 17(12.1%) patients then miliary shadowing in 17(12.1%) patients. Moreover,
The CXR findings appeared mainly in the right lung rather than the left, as shown in table 3.

Table 3: Chest X ray (CXR) findings of pulmonary TB in studied patients

Site of the lesion

Total
Chest X ray findings Right lung Left lung Bilateral
No. % No. % No. % No. %
Nonhomogeneous opacities 51 56.6% 5 29.4% 14 42.4% 70 50%
Cavity lesions 24 26.7% 4 23.5% 2 6% 30 21.4%
Pleural effusion 10 11% 6 35.2% 1 3% 17 12.1%
Miliary shadowing 1 1.1% 0 0.0% 16 48.4% 17 12.1%
Consolidation 4 4.4% 2 11.7% 0 0.0% 6 4.2%
Total 90 100% 17 100% 33 100% 140 100%

Results of Sputum Smears in Studied Patients: Furthermore, early morning sputum samples for Ziehl- Neelsen
stain were obtained from all patients, which revealed positive results in 42 (59.2%) males patients and 37 (53.6%)
of females patients, The total positive results were 79 (56.4%) patients, this relation was statistically not significant,
as shown in table 4. All patients were negative for HIV. This relation was statistically not significant as shown in
table 4.

Table 4: Results of sputum smears in studied patients

Test Males Females Total P value
Positive 42 59.2% 37 53.6% 79 56.4%
Sputum for AFB Negative 29 40.8% 32 46.4% 61 43.6% >0.05 NS
Total 71 100% 69 100% 140 100%

The Outcome of Treatment with anti TB Drugs in Studied Patients: All patients were received antituberculous
regimen, 12 (8.6%) patients represented new cases, 110 (78.6%) patients were cured, 10 (7.1% ) patients were
relapsed, while defaulted and failed patients represented as 4 (2.9%) patients for each one of them, without
significant differences between males and females, as shown in table 5.
Table 5: The outcome of treatment with anti TB drugs in studied patients
Sex
Total P value
Males Females
Total patients 71 100% 69 100% 140 100%
New case 7 9.9% 5 7.2% 12 8.6%
Cured 57 80.3% 53 76.8% 110 78.6%
Treatment outcome

>0.05 NS
Relapsed 4 5.6% 6 8.7% 10 7.1%
Failed 0 0% 4 5.8% 4 2.9%
Defaulted 3 4.2% 1 1.4% 4 2.9%

Discussion Chest X ray (CXR) Findings of Pulmonary TB in

Studied Patients: In this study the most common CXR
The General Demographic Characteristics of Patients
findings was nonhomogeneous opacities presented
with Pulmonary TB: The mean age of affected patients
in 50% patients followed by cavity lesions in 21.4%
in this study was 42.7 ± 15.7 years. A study conducted
patients, pleural effusion in 12.1% of patients then miliary
by Al-Kadhimi HM et al in Baghdad showed that the
shadowing in 12.1% of patients. The CXR findings
majority of pulmonary TB patients are belong productive
appeared mainly on the right lung rather than the left.
age group.(10) Furthermore, most of patients in this study
These findings were consistent with those of AL-
were beyond low education, low income and displaced
Jubouri AM et al a study in Baghdad that most reported
families, resulting in a high economic burden for patients
radiological findings are nonhomogeneous opacities
(during transportation, hospital stay and reduced working
hours) and society.(11) The WHO calculates that an and cavity lesions as 48% and 37% respectively without
average TB patient loses three to four months of work significant differences between right and left lung.(18)
time, and up to 30% of annual household earnings.(11) Jumaah HM et al showed the right lung was affected
more frequently than the left lung, which may be
Moreover, the present study revealed that the mean attributed to anatomical factors.(19) Furthermore, cavitary
BMI of patients was 21.4 ± 2.4 (Kg/m 2), which is still pulmonary tuberculosis associated with more sputum
within lower normal limit. Sultan KS et al and Yen YF smear positivity, more hemoptysis and more infection
et al noticed that low BMI is associated with high risks spread.(20)
of mortality during TB treatment.(12,13)
Results of Sputum Smears in Studied Patients: In
Symptoms of Pulmonary TB in Studied Patients: present study, early morning sputum samples for Ziehl-
Moreover, this study showed that the most common Neelsen stain were obtained from all patients, which
presenting symptoms were cough and sputum present in revealed positive results in 56.4% patients, however,
96.6% of patients, followed by fever 97.1%, it was still below that of WHO target, which is 70%.
sweating (21,22)
A study done by Khattak MI and colleagues, in
89.3%, anorexia 66.4%, and weight loss 51.4% of Pakistan showed 52% of patients had positive sputum
patients. Karadakhay K et al in Sulaimaniyah study AFB results.(23) The finding from Ethiopia revealed low
reports that most common symptoms of pulmonary TB case detection rate achieved as 21.6%.(21)
are cough, sweating, fever, fatigue and weight loss, and
these symptoms are related to the severity of the disease. The Outcome of Treatment with Anti TB Drugs in
(14,15)
Achkar JM et al observed that cough lead to an Studied Patients: This study implies that percentage
increased exposure of close contacts, and hemoptysis of new cases was 8.6%, it means that pulmonary TB is
is often associated with cavitary lesions, and therefore still growing problem in our locality. The cure rate was
could be considered a sign of advanced pulmonary TB. 78.6% which reflects the effective role of TB centers in
(16)
The Infectious Disease Society of America (IDSA) Salahaddin Governorate in management of tuberculosis,
and Centers for Disease Control and Prevention (CDC) but it is still below the recommended target of 85% by
recommend that pulmonary TB should be suspected in the WHO.(24,25) Relapse rate was 10%, it could be either
any patient who has persistent cough for more than 2 due to lack of compliance or emergence of multidrug
weeks with or without other signs and symptoms.(17) resistance TB, while defaulted and failed patients
represented as 4 (2.9%) patients for each one of them. American Public health Association & WHO
Karadakhy K et al study in Sulaimaniyha reported publication 2004. P. 560-572.
that
89% of patients were treated successfully and 3% were
defaulted, higher percent of cure in his study is due to
application of DOTS strategy.(15) Other studies, from
Turkey reveals 93% cure rate and 4% default rate, while
from Ethiopia reports a successful treatment rate of 60%
and a default rate of 9%. (26,27)

Iqbal Z et al study reported that before

application
of DOTS the cure rate was only 48.6% which rose
to
94.8% after DOTS, while the default rate which was
initially 19.8%, declined to less than 1% after DOTS,
which means improvement in treatment outcomes after
the implementation of DOTS strategy.(28)

Iraqi crises, including armed conflict and population

displacement, lead to destruction of basic medical
infrastructure, inhibit immunization programs, and
cause significant decrement in healthcare services and
medicines. Unfortunately, these conditions forced TB
patients to interrupt their treatment, faced personal
instability and difficult living conditions, which leads
to decrease treatment success rate and increase the
incidence of multidrug resistant-TB.(29.30)

This study concluded that pulmonary tuberculosis

is still growing problem in this locality, it is common
among low education, low income and displaced
patients.

Conflict of Interest: There are “NO CONFLICT OF

INTEREST”.

Source of Funding: Self.

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DOI Number: 10.5958/0976-5506.2019.01626.7

The Relation between Homocysteine, Oxidative Stress and

Atherosclerosis Disease

Ekhlas Abdallah Hassan

Wafaa Sh. Al-Zuhairi, Alzahraa Ibrahim Abdulmajeed, Department of Chemistry, College of
Science, University of Diyala, Baquba, Diyala, Iraq

ABSTRACT
Homocysteine(Hcy) may promote atherogenesis through oxidativestress. Malondialdehyde (MDA), which
produced through peroxidation of lipid. It is widely used in estimating the oxidative stress. We aimed to
evaluate the serum Hcy levelsand serum MAD in atherosclerosis patients and to find whether these
variables are associated with the severity of atherosclerosis disease. Sixty patients diagnosed with
atherosclerosis diseases were included in our study. Patients were divided to three groups(Low risk=
1.0, moderate risk
= 3.55, and high risk= > 6.15) according to the value of atherogenic index. Fifteen healthy individual, as
control group.Serum MDA is estimated by methods of Benge ( 1978). Hcy were quantitatively determined
in patients and control subjects by ELISA test. The receiver operator curve (ROC) analysis of the
forthcoming variations revealed the descending order of ( Hcy = 0.959; MAD = 0.832;TC = 0.609; LDL =
0.594;and Tri
= 0.502) that showed significant variation. The rest of parameters (uric acid, HDL and albumine) failed to
occupy a significant ROC area.In our study,we found serum each Hcy and MAD was significantly
increased in patients than control; it was gradually increased with increase atherogenic index, affected by
the severity of disease, and significantly increases in third group than first group of patients. Person linear
correlation revealed a significant positive linear correlation with serum Hcy and MAD and increased risk
factor of atherosclerosis disease in the three progressed groups of patients. In summary, there is a
significant relation between Hcy levels, MDA, and atherosclerosis diseases. This relationship could cause
early development of atherosclerosis diseases even in males. So we suggest that Hcy and MAD might be
taken into consideration through the evaluation of atherosclerosis patients

Keywords: Atherosclerosis, homocysteine, malondialdehyde, oxidative

stress
Introduction mechanisms by which Hcypromotes atherosclerosis is
not fully understood (3).Hcy is nonessential amino acid
Atherosclerosis is a complex and chronic disease
of molecular weight (268 dalton), formed during the
involving gradual accumulation of lipids, collagen,
metabolism of methionine (4)(5). Recently, in both clinical
elastic fiber, and proteoglycans in the arterial wall.
and experimental studies it has been discovered that
Pathogenesis of atherosclerosis is becoming a moderate increase of plasma Hcy level to confer an
better understood (1).Because of some studies showed independent vascular disease risk factor (6)(7). It has also
clearly provides now free radical involvement in the been revealed that hyperhomocysteinemia (HHcy) lead
pathogenesis of atherosclerosis itself(2). Hcy may to the hurried process of atherosclerotic in diabetic
promote atherogenesis through oxidative stress the patients (8). In this study, we aimed to evaluate the serum
Hcy levels and serum MAD in patients with
atherosclerosis disease and to find whether these
Corresponding Author:
variables are correlated with the severity of disease
Ekhlas Abdallah Hassan
atherosclerosis disease.
Wafaa Sh. Al-Zuhairi, Alzahraa Ibrahim
Abdulmajeed Department of Chemistry, College of
Science, University of Diyala, Baquba, Diyala, Iraq Material and Method
Email: [email protected] This study has been carried out at the
consultative
clinic in Baquba, for the period from September 2016 to
538 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 538

May 2017. The study included (75) subjects (35 females descending order (Hcy = 0.959; MAD = 0.832; TC
and 40 males) with age range ( 59-72 ) years, (15) =
healthy individuals as control group and (60) patients(29 0.609; LDL = 0.594;and Tri = 0.502) of parameters that
females and 31 males) with atherosclerosis. Patients were showed a significant variation. The rest of parameters
divided to three groups (Low risk= 1.0, moderate risk = (Uric Acid, Albumin and HDL-C) failed to occupy a
3.55, and high risk= > 6.15) according to the value of significant ROC area (Table 1)
atherogenic index. blood sample was collected from each
participant after (12-14) hours fasting. For all participant Table 1: ROC analysis for the investigated
BMI = weight/(height)2 was calculated. The enzymatic parameters in atherosclerotic patients and controls
methods were used to estimate the following variables
:triglyceride, total cholesterol (TC) concentrations. LDL- Parameter ROC Area P≤
cholesterol concentrations were measured by using the Hcy 0.926 0.001
Friedewald formula. Serum MDA is estimated by MAD 0.832 0.01
methods of Benge (1978) (9). Homocysteine were TC 0.609 0.01
quantitatively determined in subjects by ELISA test. LDL-C 0.594 0.05
Atherogenic index is the ratio between total Tri 0.502 0.05
cholesterol/HDL- cholesterol(10). To calculate Atherogenic
HDL-C 0.402 (N.S)
index the following equation was used (11): Atherogenic
Uric Acid, 0.452 (N.S)
Index = TC/HDL- C.
Albumin 0.372 (N.S)

Result Distribution of Patients According to Value of

Atherogenic Index: We notice that there have been
Receiver Operator Curve (ROC) Analysis: To
a highly significant differences (P<0.01) in value of
discriminate between atherosclerotic patients and
atherogenic index. (73.3 %) of patients have high risk=
controls by employing the forthcoming investigated
> 6.15, while (15%) of the patients are considered to
parameters, the ROC analysis was applied. Such
be moderate risk having 3.55 and (11.6%) of them are
analysis Allows to regulate the parameters according to
considered to be goals for atherogenic index in patients
the ROC area that can occupy and if such occupation
with atherosclerosis was low risk =1as shown in table 2
is significant or not. The ROC analysis showed the

Table 2: Distribution of patients according to value of atherogenic index

Comparison of Significance
Value of Atherogenic Index Gender N %
by Kruskal-Wallis Test
Males 3
Lowrisk = 1.0 11.6
Females 4
Males 3
moderate risk = 3.55 15
Females 6 P<0.01
Males 25
high risk = > 6.1 73.3
Females 19
Total 60 100

Serum Homocystein (Hcy) and Correlation with mL, respectively) in the three progressed groups of
Atherogenic Index: Figure (1and 2) Showed the Atherosclerosis. Such differences were significant in
serum Hcy a gradual increased level in Atherosclerosis patients (P ≤ 0.05), moreover the r value (0.822) was
patients (2.26 ± 0.21,4.09 ± 0.25, and 8.45 ± 0.16mg/ also significant (P ≤ 0.001) in patients.
Figure 4: Correlations of MAD and the value
Figure 1: Serum Hcy level in Atherosclerosis atherogenic index in patients groups
patients
Discussion

Over the past three decades, homocysteine has

relieved as uncommon risk independent marker for the
procession of CVD (12). Baushey et al. (1995) have found
a linear relationship between vascular risk and Hcy
levels, that a 5 µmol/L increase in Hcy concentration
was correlating with an increase in risk of vascular about
thirds one (13). The relation between CVD and Hcy had
investigated by several predictable studies. Many (14)(15)
but not whole (16)(17) get it a positive relation. None of
Figure 2: Correlations of Hcy and the value the preceding studies, however, studied the possibility
atherogenic index in patients groups of association between oxidative stress and Hcy with
SerumMADand correlation with atherogenic index: respecting to risk of Atherosclerosis.
The patients group demonstrated a gradual increase of
The results of the current study propose that serum
MAD level (0.32 ± 0.12 0.65 ± 0.19M and 1.09 ± 0.23μ
Hcy is a predictor of atherosclerosis. However, levels
mol/L, respectively) in the three groups of
of Hcy are correlated with value of atherogenicindex
Atherosclerosis. Such difference was significant (P ≤
Earlier studies on the serum level of Hcy as a predictor
0.05), and the r value (0.59) of correlation was also
positively significant (P ≤ of atherosclerosis are argumentative. Clark et al.(1991),
0.01) as shown in figure (3 and 4) One main property of total Hcy(tHcy) is might to
prompt atherogenesis Hcy reason atherogenesis by
increasing DNA synthesis of a gene called Cyclin A
which in turn prompt replication of an uncontrollable
cells in one region within the blood vessels lining (18).
Hcy has been supposed to induce atherosclerosis by
the inducement the endothelium of oxidative injury,
which is a crucial step in the restraint to injury
hypothesis(19) (20) Finally, harmony to Melvin et al. (2004)
demonstrated increasing of serum Hcy in
atheroscleropathy and concluded that homocysteinemia
being an independent risk factor for CVD as happens in
ischemic disease such as myocardial infarction and
Figure 3: MAD serum level in Atherosclerosis stroke and thrombotic events (21).
MAD level was found to be higher in patients r value was also significant in patients. These results
compared with the control groups (P > 0.01) as shown in are similar to the observations of a number of other
table (1). These results are agreement to the some investigators (29) (30).Misra et al.(1994) relived that
pervious study (22) (23). Peroxidation of lipid produced Hcy thiolactone, which forming during complicated
MDA which is used widely in estimating oxidative rearrangements of Hcy is chemically reactive and
stress therefore; the evaluation of MDA may be used to acylates free amino groups in protein such as the side-
decide whether a process of lipid peroxidation has taken chain lysine groups . In the process of
place (22). The measurement of MDA has widely been homocysteinylated proteins formation moreover
used to detect oxygen free radicals-mediated cell development oxidative stress and homocysteinylated
injury. In patients with atherosclerotic disease lipid proteins become damaged and may lose their biological
peroxidation activity is accelerated. So higher MDA activity. Jones et al. (1994), confirmed that oxygen free
level is associated with the clean out of antioxidant and radicals generated from Hcy by noticing Hcy toxic
several forms of scavengers. It can be suggested that effects and in the presence of Cu2+, and their
higher MDA levels might be a biochemical marker for association with increased peroxidation of lipid, which
atherosclerotic disease (23). was inhibited by catalase and attenuated by desferal(31).
Oxygen radicals have been confirmed to reason injury
There is no doubt about the relation between serum
of endothelial (32)
lipids profile and the risk of chronic disease including
CVD. As well as the metabolic syndrome, which The patients group demonstrated a gradual increase
is characterized by obesity, hypertension, glucose of MADlevel in the thrid groups of Atherosclerosis.
intolerance, visceral, and dyslipidemia that increases the Such difference was significant, and the r value of
risk for CVD. Our investigation agrees with Laaksonen correlation was also positively significant. There are
et al. (2002) (24).The propagation of atherosclerosis
several previous studies that have studied the relation
a gradual increase with age. The aging process may
between MAD and aherosclerosis disease.Kostner et al.
promote modification of lipoprotein metabolic, which
revealed higher levels of MDA in patients with
lead to an increase in the receptivity oxidation of the
coronary artery (33). Pucheu et al. showed an increase in
LDL-C because of their small size. So it is supposed
that LDL are associated with increased atherogenesis(25). level of serum MDA following thrombolysis in acute
HDL-C is believed to act as cholesterol scavenger. It MI patients, but no significant differences they could
removes cholesterol first by absorption on its surface, find between control group and stable angina pectoris
and then facilitates enzymatic conversion to cholesterol patients group (34). In (2001) Cavalca et al, in their study
esters which moves to the core of the HDL particle about oxidative stress and Hcy in coronary artery
and returns to the liver. This property of removing disease, he observed, higher significant levels of
cholesterol from peripheral tissues is thought to give MDA were estimated in patients with coronary artery
HDL its favorable cardioprotective properties (26)(27).So when compared to the healthy group (35).In our study,
for each 1mg/dL decrease in concentration of HDL-C, we found serum MAD was significantly increased in
the risk for atherogenesis is increased by 2-3%in patients patients than control; it was gradually increased with
with low levels of HDL-C. increase atherogenic index, affected by the disease
We showed a highly significant differences in severity, and significantly increases in third group than
value of atherogenic index. Most of patients have high first group of patients. We believed that MDA
risk, while remind of the patients are considered to be possibly also be associated with Atherosclerosis
moderate and low risk .unexpectedly high prevalence of involvement.
coronary atherosclerosis in Iraqi people, atherosclerosis
disease is more prevalent in males than females, and it Conclusion
is increasing with age progression, and the prevalence
becoming 100% after the age of 40 years old (28) There is a significant relation between Hcy levels,
MDA, and atherosclerosis diseases. This relationship
The level of serum Hcy a gradual increased level could cause early development of atherosclerosis
in the third progressed groups of Atherosclerosis. Such diseases even in males. So we suggest that Hcy and
differences were significant in patients; moreover the MAD might be taken into consideration through the
evaluation of atherosclerosis patients.
Ethical Cearance: This study was conducted with McGrow-Hill Companies, United States.
the 2003,Ch.26,pp,219-20
consent of the volunteers and without mentioning
the
names with the complete privacy of volunteers
10. Benge J.A. and Aust S.D. Estimation of serum
Source of Funding: Self Malondialdehyde level in hoffee P.A. and Jones
M.E. (eds), Methods in Enzymology Hoffee
Conflict of Interest: Nil Jones. Academic Press, New York, San Francisco,
London, ASubsidinary of Harcoart Brace
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DOI Number: 10.5958/0976-5506.2019.01627.9

Comparison of the Educational Effect of Two and Three

Dimensional Books on Dental Anxiety in Children with
Hearing Impairment (Aged 7–9 Years)

Eva Fauziah1, Selvyra Rachmawati2, Aprillia Puspita Rachmadani2, Cahyanti Wydiastuti

Susilo2
1
Lecturer, Pediatric Dentistry Department, 2Resident, Pediatric Dentistry Residency Program, Faculty
of
Dentistry, University of Indonesia, Jakarta 10430, Indonesia

ABSTRACT
Introduction: Dental anxiety is common in children prior to dental treatment especially in hearing
impaired children because of difficulties in communicating their fears. One of the method to overcome
dental anxiety is positive image.
Materials and Method: The study was done in 21 children 7-9 years old with hearing impairment. Each
children were educated by two and three dimensional book “Aku dan Gigiku”. Dental anxiety was assessed
by measuring respiratory rate, salivary alpha amylase, and electrodermal activity.
Results: Statistical data were analized with independent t-test and mann-whitney test. There were
difference
but not significant in delta value between two and three-dimensional book “Aku dan Gigiku”.
Conclusion: This study show that two and three dimensional book “Aku dan Gigiku” has positive effect on
dental anxiety by decreasing breathing frequency, salivary alpha amylase, and electrodermal activity.
Keywords: Dental Anxiety, Two Dimensional Book, Three Dimensional Book, Children with Hearing
Impairment.
Introduction overcome anxiety is positive pre-visit imagery,
in
Dental anxiety is common in children prior to dental
treatment. Children with communication barriers, such
as hearing impairment, are more likely to experience
higher levels of anxiety due to difficulties in
communicating their fears. Lack of communication
between dentists and pediatric patients owing to the
doctor’s minimal skills in the management of children
with anxiety can affect treatment success. Dental anxiety
causes uncooperative behavior and introduces various
obstacles; thus, treatment will not be optimal because a
lot of time is wasted. Dental anxiety is manifested in
different ways in each individual, for instance, specific
physiological reactions, such as increases in salivary
alpha amylase levels, respiratory rate, electrodermal
activity, heart rate, and blood pressure can occur.1,2

According to the American Association of Pediatric

Dentistry, effective communication is essential.3 For
children with hearing impairment, various types of
media can be used to communicate, including writing,
drawing, and lip-reading [4]. One of the methods to
which the patient’s parents show them positive images
of dentistry or dental care in the waiting room prior
to dental treatment. The purpose of positive pre-visit
imagery is to provide visual information to children and
parents regarding procedures performed by the dentist
and to provide opportunities for children to ask questions
prior to dental treatment.3

In the present study, the type of media used to

reduce dental anxiety in children with hearing
impairment were the two- and three-dimensional
versions of the book “Aku dan Gigiku,” which contains
material on oral hygiene, dentist visits, and an
introduction to dental devices that are expected to be
used, with a view to reducing dental anxiety in children
with hearing impairment.

Materials and Method

The present study was conducted at SDLB Santi
Rama Cipete, South Jakarta, and aimed to analyze the
differences in the educational effects of two- and three-
dimensional versions of the book “Aku dan Gigiku”
on the respiratory rate, salivary alpha amylase levels,
and electrodermal activity in children with
hearing
544 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

impairment. This was an experimental clinical study version of the book, Each measurement was performed
comprising total 42 children with hearing impairment thrice and the obtained values were averaged; the delta
(age, 7−9 years; 26 boys and 16 girls). Subjects were value, which is the value that was analyzed, was taken as
divided into two intervention groups: one using the the difference between the second and first values.
three-dimensional version of the book and another using
the two-dimensional version. Inclusion criteria were
Results and Discussion
children with hearing impairment aged 7−9 years with
communication level class 1, 2, or 3 SDLB and an IQ Data for the respiratory rate, salivary alpha amylase
level of >90, and children who had never visited a levels, and electrodermal activity were tested for
dentist. normality using the Saphiro−Wilks test (sample size,
n = 42). The results of the data normality test showed
The respiratory rate, salivary alpha amylase levels,
that the respiratory rate in both intervention groups
and electrodermal activity of the subjects were measured
was normally distributed at p ≥ 0.05. Furthermore, a
twice in both intervention groups; the first measurement
parametric independent t-test resulted in a significance
was performed prior to the intervention, whereas the
value of p< 0.05.
second measurement was performed following the
intervention with either the two- or three-
dimensional

Table 1: Comparison of the delta value for the frequency of breaths between the two- and three-dimensional
book intervention groups

Mean ± SD (breaths per minute) p

Variable n
1 2 FN FN Δ
Three-dimensional book intervention group 21 23.490 ± 2.782 19.654 ± 4.471 −3.837 ± 4.808
0.062*
Two-dimensional book intervention group 21 22.698 ± 2.089 21.016 ± 1.851 −1.174 ± 1.169
Independent t-test *significance = p< 0.05; FN1 = First respiratory rate; FN2 = Second respiratory rate

Table 1 shows that the mean first and second breathing frequency in the three-dimensional book
intervention
group were 23.490 ± 2.782 and 19.654 ± 4.471 breaths per minute, respectively, and that the delta value was −3.837
±
4.808 breaths per minute. These results show that the respiratory rate decreased following intervention with the
three- dimensional version of the book “Aku dan Gigiku.” Similarly, the breathing frequency in the two-
dimensional book intervention group decreased, with a delta value of −1.174 ± 1.169 breaths per minute. An
independent t-test was used to test the hypothesis (p = 0.062). Thus, it can be concluded that there was no
statistically significant difference (p> 0.05) in the respiratory rate between the two- and three-dimensional book
intervention groups.
Median (minimum–maximum) p
Variable n
ASS ASS Δ
Table 2: Comparison of the delta value for the salivary alpha amylase levels between the two- and three-
Three-dimensional book intervention group 21 27 (3−170) 11 (2−101) 16 (−7–69)
dimensional book intervention groups
Two-dimensional book intervention group 21 18 (2−44) 10 (3−24) 11 (−11–26)

1 2

0.199*

Mann−Whitney test, *significance = p ≤ 0.05; AAS : First alpha amylase score; AAS : Second alpha amylase
score 1 2

Table 2 shows that the delta value for the salivary alpha amylase levels of the three-dimensional book
intervention group was 16 (−7−69) and that for the two-dimensional book interventional group was 11 (−11−26).
These data show that the median alpha amylase levels decreased in both intervention groups. A non-parametric
545 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
Mann−Whitney test was used to test the hypothesis (p = 0.199), which indicates that there was no significant
difference in the salivary alpha amylase levels between the two- and three-dimensional book intervention groups.
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 545

Table 3: Comparison of the delta value for the electrodermal activity between the two- and three-
dimensional book intervention groups

Median (minimum –maximum) (µS) p

Variable n
1 2 EA EA Δ
Three-dimensional book 3.334 2.358 −1.346
21
intervention group (1.121−9.255) (0.638−5.702) (−5.386−0.000)
0.001*
Two-dimensional book 1.410 1.020 −0.390
21
intervention group (0.023−4.318) (0.849−4.247) (−0.872−−0.071)
Independent t-test significance = p< 0.05; EA = First Electrodermal activity; EA = Second
*
Electrodermal 1 2
activity; µS: micro Siemens
Table 3 shows that the delta value for the system, which is responsible for emotional regulation.7,8
electrodermal activity of the three-dimensional book
intervention group was -1.346 (-5.386−0.000) and that The three-dimensional version of the book “Aku
of the two-dimensional book intervention group was dan Gigiku” is about oral health, the conditions of a
-0.390 (-0.872−-0.071). These results show that the healthy and unhealthy mouth, the causes of dental caries,
median electrodermal activity decreased in both and how to maintain good oral health.Pop-up books play
intervention groups. A non-parametric Mann−Whitney a role in providing information prior to dental visits
test was used to test the hypothesis (p = 0.001), which by introducing oral hygiene and dental care in a fun
indicates that there was a significant difference in manner. This book has become one of the main tools
electrodermal activity between the two- and three- in the management of mild anxiety in children with
dimensional book intervention groups. hearing impairment. For moderate and mild anxiety,
visual or auditory stimuli, such as music sounds, videos,
General anxiety typically occurs in children with or positive images, are helpful in reducing anxiety.1 The
hearing impairment owing to barriers in communication, American Academy of Pediatric Dentistry(AAPD) has
particularly regarding difficulties in conveying stated that attractive images and colors in books can act
emotions. This high level of anxiety affects the complex as a medium in a positive pre-visit imagery approach to
communication process; thus, information becomes decrease dental anxiety.3
more difficult to understand. Anxiety can lead to
uncooperative behavior in children, which contributes to The results presented in Tables 1, 2, and 3 show
avoidance of dental checkups, thereby leading to dental revealed no statistically significant differences (p> 0.05)
complications and oral problems.5,4 between the respiratory rate, salivary alpha amylase
levels, or electrodermal activity between the two- and
Subjects involved in the present study were children three-dimensional book intervention groups. These
with hearing impairment who had never visited a dentist. results indicate that both types of books are similarly
Anxiety is an emotional response in the form of fear of effective as oral health education media in overcoming
an unknown threat or a situation that has not yet taken dental care anxiety in children with hearing impairment
place.6 Physiological responses as a result of anxiety prior to oral prophylaxis, as characterized by decreases
include increases in respiratory rate, salivary alpha in the respiratory rate, salivary alpha amylase levels,
amylase levels, electrodermal activity, and heart rate, and electrodermal activity. Education provided prior
in addition to palpitations, sweating, and abdominal to dental treatment can inculcate a sense of security in
discomfort or pain. An increased respiratory rate can children with hearing impairment through vision, touch,
be caused by negative emotions, such as anxiety, as and facial expressions.4,9,10,11
the physiological response of the body changes.1 The
response caused by anxiety occurs due to increased The Galvanic Skin Response (GSR) logger sensor
activity of the autonomous nervous system, particularly is a tool for measuring electrodermal activity. Emotional
the sympathetic nerves. Major respiratory controls are and sensory stimulation causes sweat production. The
performed by the brain stem; however, the end result of GSR logger sensor is used to measure sweat from the
breathing may be affected by the amygdala in the limbic sweat glands in the hand.12 As a result of the stimulation,
546 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

the amount of sweat increases and so does the skin 4. Suhani R, Suhani M, Badea M. Dental anxiety
conductivity.13 Electrodermal activity measurement was and fear among a young population with hearing
selected as the parameter to be evaluated in the present impairment. Clujul Med. 2016;89(1):143-9.
study because it is one of the simplest tools to measure 5. Dougall A, Fiske J. Access to special care
the psychophysiological activity of anxiety in a dentistry,
quantitative manner.14,15 Najafpour et al. (2016) part 2. Communication. Br Dent J. 2008;205(1).
reported that the GSR logger sensor is a reliable and 6. American Psychiatric Association. Diagnostic and
valid measurement tool for assessing dental anxiety in Statistical Manual of Mental Disorders: Arlington,
children in clinical settings. The GSR may help identify American Psychiatric Publishing; 2013.
clinically anxious children prior to dental treatment to
7. Holstege G, Beers CM, Subramanian HH. The
provide appropriate interventions.14
Central Nervous System Control of Respiration:
Great Britain, Elsevier Science; 2014.
Conclusion
8. Kreibig SD. Autonomic nervous system activity in
The two- and three-dimensional versions of the emotion: A review. Biol Psychol. 2010;84(3):394-
book “Aku dan Gigiku” did not significantly differ in 421.
their effect and similarly decreased anxiety in children 9. Bunawan L, Yuwati C. Penguasaan Bahasa Anak
with hearing impairment aged 7−9 years, as Tunarungu: Jakarta, Yayasan Santi Rama; 2015.
characterized by the decreases in respiratory rate,
salivary alpha saliva levels, and electrodermal activity. 10. Achmad, H. et. al. Prevalence of Medically
Compromised Children Regarding Dental Caries
and Treatment Needs in WahidinSudirohusodo
Acknowledgments
Hospital. Journal of International Dental and
This paper has been fully supported and financed Medical Research. 2017:10 (3); 915-19
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University of Indonesia. S, Jamali Z, Shirazi S. Can Galvanic Skin
Conductance be used as an Objective Indicator of
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ethics escaped by the number: 39/Ethical Approval/ blog/galvanic-skin-response/
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Mardiana And Andam Dewi Suci. Analysis Of
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DOI Number: 10.5958/0976-5506.2019.01628.0

Effectiveness of an Education Program for School Age

Children Related to Management of Growth Hormone
Deficiency University of Baghdad-College of Nursing

Fatima H. Abbas1, Eqbal GH. Ma’ala2

1
Academic Nurse, Ministry of Health, Iraq; 2Professor, Pediatric Nursing Department, College of
Nursing, University of Baghdad, Iraq

ABSTRACT
Study aimed to determine effectiveness of educational program on children with growth hormone deficiency
knowledge at and determine relationship between knowledge and their general information.
Methodology: A quasi-experimental study was carried out at Child’s Central Teaching Hospital, Medical
City of Al Imamian Al Khadhmain Teaching Hospital, and National Centre for Treatment and Research
of Diabetes, Specialized Center for Endocrine Diseases and Diabetes; and Department of Medical City
(Children Welfare Teaching Hospital) The study included a purposive sample of (80) children with growth
hormone deficiency who were attending to outpatient endocrine clinics and centers. Descriptive statistical
analysis procedure (frequency, percentage and mean of score) and inferential analysis procedure (person
correlation coefficient, chi-square test, t-test and Z score) were used to analysis data.
Results: The findings of the study indicated that there is an effectiveness of an educational program upon
school age children related to the management of their growth hormone deficiency. There is no statistically
significant difference between child’s knowledge about their management and their demographic data.
The researchers recommended to (1) provide specialized nurses in endocrine centers and clinics to give
high quality care, (2) implement the educational program to educate children and their families at schools,
nurseries and other institutes, and (3) encourage children with growth hormone deficiency and their care
givers about management through initiate of training session as group and incentive for children by
educational media like CD, pamphlet, about normal range of height, weight, nutrition, exercise, and
medication.

Keywords: School-age Children, Growth Hormone

Deficiency
Introduction great development in the past few decades in sciences
of biological work and growth biology at molecular,
Growth is a systematic and organized process it is
cellular and serology helps to discover this physical
begins at ordered conception. Growth has a sophisticated
and maturational process mechanisms and the key
interaction between hormones, genes and nutrients.
that controlled it, have participated in the knowledge
The human growth and maturation can be affected
of the growth disorders pathophysiology. The genetic
and controlled by several hormones, specially growth
revolution is re-inventing medicine. This understanding
hormone (GH), which is secreted by the pituitary gland
(1) helps us to remake new management like molecular
.
genetic techniques which clarified the etiology of growth
The Growth and development process consider disorders. Expression of effective and scheduled of the
the growth hormone (GH) program is important for growth
most important and vital features of a child’s life.
The
in stature such as metabolic homeostasis (2).
Corresponding Author:
Fatima H. Abbas, Assessing pediatric wellbeing or growth assessment,
Medical City Directorate, High Vocations Institute, through anthropometric measurement (height, weight,
Email: [email protected] head circumference, chest circumference, abdomen
548 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 548

circumference, skin fold thickness, body mass index, children knowledge toward nutrition status,child
wrist circumference, bone age and growth chart”. knowledge toward exercises and it is effect on child
Height, weight, and bone age most common for use to height and growth, and children knowledge toward sleep
detect of growth hormone deficiencies (3-4). disturbance and it is effect on growth.

Growth hormone is a peptide hormone that Method of while the intervention procedure:
stimulates growth and development. Growth hormone is 1. Approval request provided to the children to
synthesized in the somatotropic cells, which are found obtain their participate agreement of the study.
in the anterior pituitary gland. Any disturbance for rate
growth hormone effect on growth and development of 2. Validity: Content validity for the early developed
the children (5). instrument was determined through the panel
of experts (who have had more than 5 years of
Nursing management for children with growth experiences in their specialty field) to investigate
hormone deficiencies is very important to improve the clarity, relevancy, and adequacy of the
normal growth and development and reduce burden on questionnaire in order to achieve the present
the child and their family through the role of nursing study’s objectives. A preliminary copy of the
education for parent about monitoring early signs and questionnaire was designed and presented to (15)
symptoms that appear for the child and indicators for experts. They were (6) faculty members from
growth deficiencies, education for the children and college of nursing/ university of Baghdad, (6)
their caregivers about nutrition of the child, special endocrinologist faculty member from ministry of
exercise that help the child, sleep pattern of the child, health (Central child teaching Hospital) (1)
and psychological status so the knowledge for children Endocrinologist from Babylon College of
and their caregivers is important to improve growth for Medicine, (1) nutritionist from Al-Kindy Collage
children and decrease burden of the problem on children of Medicine and (1) psychologist from Ibn Rushed
and their family and society (6). Hospital.

Method and Material 3. Determination of the questionnaire was based on

test –retest method.
Method
Statistical Analysis: Descriptive and inferential
Research Design: A quasi-experimental design was statistical analysis procedure were used to analysis data.
followed to conduct this study.

Setting: Study carried out in outpatient endocrine clinics Results

and centers at Baghdad City hospitals.
Data analyzed reveal that table (1) show the child’s
Subject: A purposive (non-probability) sample of (80) age mean is 10.36 ± 1.75; two-third age 12-years-old (n
children with growth hormone deficiency agree to = 32; 40.0%).
participate in this study.
Concerning child’s gender, more than a half are
Tool of the Study: A study instrument was designed females (n = 43; 53.75%) compared to males (n =
and constructed by the researcher to measure the 37;
variables underlying the present study. A questionnaire 46.25%).
format construction through reviewing of literature and
Table (2) There are statistically significant
related studies. The tool of the study consisted of two
parts (Child Demographic Characteristic and their differences in children management follow-up (Mean =
knowledge questionnaire related to management of 47.5625, 53.3275, 69.443) respectively.
hormone deficiency) Tables (3) show there is no statistically significant
Part 1: A demographic data sheet, consisted of (2) difference in children’s management of growth hormone
items, deficiency, nutrition, exercise, sleep, and psychological
which included age and gender, status their demographic data like child’s gender groups
in the pre-test time.
Part 2: knowledge questionnaire designed to measure
the children knowledge and it consists of (48) items Table (4) show there is statistically significant
that concerned with: growth hormone replacement differences in children’s management of nutrition,
therapy dosage, rout of administration and side exercise, and management of sleep and children’s
effects, gender groups in the posttest I (p-value = .005).
Table (5) show there is a statistically significant Table 2: Distribution and association of children
difference in children’s management of exercise between knowledge
children’s gender groups in the post-test II (p-value
=
Std. Std. Error
.005). Management No. Mean
Deviation Mean
Pretest 80 47.5625 3.73469 .31754
Table 1: Distribution of children general t=82.513 df=79
information (n = 30) Posttest I 80 53.3275 3.8980 .43335
t=147.121 df=79 p-value = .000, .000, .000
Variables Frequency Percent Posttest II 80 69.443 1.0832 .11286
Child’s Age (Years): Mean (SD): 10.36 ± 1.75 t=340.568 df=79
7-8 16 20 Correlation between child’s age and their
knowledge
9-10 18 22.5
Knowledge Knowledge Knowledge
11-12 46 57.5 Variables
Pretest Posttest I Posttest II
Total 80 100.0 1. Child’s
0.346 0.196 0 .142
Child’s Gender Age
N = number, Male
Std= standard deviation,
37 t= t test, df =
46.25
degree of freedom
Female 43 53.75
Total 80 100.0

Table 3: Distribution and Association of children’s knowledge and their gender pre test
Male Female
N Mean df Sig. T S.D N Mean df Sig. T S.D
Child’s
Management
37 31.2703 .332 4.62270 78 .741 43 30.8605 .339 6.15120 76.685 .735
of Growth
Hormone
Child’s
Management 37 19.5135 1.149 2.98721 78 .254 43 18.7442 1.149 2.98483 76.212 .254
of Nutrition
Child’s
Management 37 15.7027 1.829 2.67566 78 .071 43 14.5349 1.844 2.98687 77.862 .069
of Exercise
Child’s
Management 37 9.3784 -1.187- 1.58730 78 .239 43 9.8605 -1.207- 1.98304 77.623 .231
of Sleep
Child’s
Management
of 37 16.0811 -.083- 3.14800 78 .934 43 16.1395 -.083- 3.12883 76.089 .934
Psychological
Status
N = number, SD= standard deviation, t= t test, df = degree of freedom

Table 4: Group Statistics for the difference in child’s management between gender groups in the posttest I
Male Female
N Mean df. Sig t S.D N Mean df Sig. T S.D.
Child’s
Management
37 43.1081 -.493- 1.57734 78 .623 43 43.2791 -.492- 1.51698 75.250 .624
of Growth
Hormone
Conted…
Child’s
Management of 37 18.3243 -.603- .85160 78 .548 43 18.4884 -.626- 1.45360 69.321 .534
Nutrition
Child’s
Management of 37 2.7027 1.063 .46337 78 .291 43 2.5814 1.076 .54478 77.993 .285
Exercise
Management of
37 13.6216 .379 1.18676 78 .706 43 13.5349 .370 .85493 64.334 .713
Sleep
Management of
Psychological 37 17.0270 .501 1.49975 78 .618 43 16.83783 .509 1.83783 77.800 .613
Status
N = number, SD= standard deviation, t= t test, df = degree of freedom

Table 5: Distribution and association of children’s knowledge and their gender posttest 2
Male Female
N Mean Sig df. t S.D N Mean Sig. df T S.D
Child’s
Management
37 44.5135 -.188- 1.12105 78 .852 43 44.5581 -.186- 1.00717 73.134 .853
of Growth
Hormone
Child’s
Management of 37 18.2973 -.918- 1.02374 78 .361 43 18.5116 -.921- 1.05497 76.850 .360
Nutrition
Child’s
Management of 37 22.2162 .389 1.05765 78 .699 43 22.0930 .401 1.65923 72.238 .689
Exercise
Management of
37 7.4595 -.378- .83648 78 .707 43 7.5349 -.381- .93475 77.868 .704
Sleep
Management of
Psychological 37 7.4595 -.378- .83648 78 .707 43 7.5349 -.381- .93475 77.868 .704
Status
N = number, SD= standard deviation, t= t test, df = degree of freedom
Discussion Teaching Hospital reported that ratio between male
and female 1.14 and (10) found (22.4%) of study sample
Concerning the children age, the two third of
(11-12) years who showed in a study (Stunting among
study sample 57.5% was (11- 12) years old (table1)
primary-school children: a sample from Baghdad, Iraq)
this result agree with (7) of the study (pattern of short
conducted in primary-school children in Baghdad.
stature attending the growth center in Al-Sulaimaniyah
they reported that most frequent of age group The Researcher stated that according growth and
was(8- development this period are conceder acritical period
12years), the study agree with (8) (Evaluation of the for life of children in this period. Physiologically, the
American-English Quality of life in Short Stature children is attention in the body image and in this stage
in the United States) show that the (54.5%) of study the bone age density after 12 years old is closed in 11–
sample (11-12) years old, the result agree with (9) of 14 in girls and 13–16 in boys) when the bone is closed.
the study Causes of short stature in patients referred to After closed the bone the medication and different aspect
the pediatric endocrinology clinic of children
Welfare
of treatment that not effect on height and weight. Finally, (pretest, post 1and post 2) (p-value ˂0.05) (table 3). The
this age of children is a final chance for treated children researcher showed that the children knowledge
with growth hormone deficiency. deference according stage of children, children in late
stage have more knowledge than early and late stage,
Concerning the children gender was more than half
knowledge improved developmentally with age, so
of study sample are female (53.75%), this result agrees
children were oriented and obeyed to constructions and
with (11) of their study (Causes of short stature in Iraqi
directions.
hospital-based study patients in pediatric endocrine clinic
of children welfare teaching hospital) found (53.33%) of The findings indicated that there was a significant
study sample is female. The study result similar with (12) association between children management and their
of his study (Evaluation of The Response of Children gender at (pretest post1 and post 2 of follow up (p value
with Short Stature to A Six Months Treatment with ˂0.05). There are statistically significant differences
Recombinant Human Growth Hormone) was found between both genders. In posttest I, posttest II male
(51.7%) of study sample is female. The result agree with rather than female in some aspect like: sleep, exercise,
(13)
of their study they found 54.3% of study sample were psychological status this variance depends on attitude of
female, This result similar with (8) found (54.5%) in the the children and over time the boys contact with peer in
study sample female. And disagree with (10) who the street and school
found (54.6%) of this study sample were males and the
remaining were females, and similar of (13) of his study
Conclusion
(Prospective study of Etiology of Short Stature in
Pediatrics Endocrinology, Imam Khomeini Hospital), The study indicated that the most of children were
Faculty of Medicine, Tehran University of Medical male and the care givers were female, most of children
Sciences, Tehran, Iran, are found (78 %) of study sample age (12) years. The findings of the present study indicate
are male. that the implementation of educational program was
effective, the management of children is improved in
Successful parent education programs help parents
acquire and problem-solving skills necessary to build first and second post-test of follow up as compared with
a healthy family. Research shows that effective parent the pre implementation of the program.
training and family interventions can change parents’
attitudes and behaviours, promote protective factors, and Recommendations
lead to positive outcomes for both parents and children. 1. Provide specialized nurse in endocrine centers
Health related causes of impaired linear growth and clinics to give high quality care.
include diverse systemic diseases, nutritional and 2. Implementation the educational program to
emotional deprivation, endocrine diseases and a wide educate children and their families at schools,
range of dysmorphic syndromes, inborn errors of nurseries and other institutes.
metabolism, and chromosomal abnormalities. Variants
3. Encouragement of children with growth hormone
of normal growth including constitutional growth delay
deficiency and their care givers about
(CGD) and familial short stature (FSS) are the most
management through initiate of training session as
common causes of short stature (14)
group and incentive for children by educational
The study result indicated that the children media like CD, pamphlet, about normal range of
management toward (growth hormone, nutrition, height, weight, nutrition, exercise, and
exercise, sleep and psychological management) domain medication.
and sub domain shows that the children management
Conflict of Interest: The researchers report no conflict
was not accepted before beginning educational program
of interest.
and the improvement in their management was clearly
observed through the first and second follow ups that Source of Funding: This study did not receive any
refer to effectiveness of the program sessions (table 2). funding from any agency.
The findings indicated that there was significant Ethical Clearance: A permission to conduct this study
association between children management and their age was obtained from the ethical committee in the College
of Nursing, University of Baghdad.
REFERENCES Alsulaimaniyah, scientific Council of pediatrics
1. Stewart PM. Current therapy for acromegaly. 2015,
Trends Endocrinol Metab 2000;11(4):128-134. 8. Bullinger, M, Sommer, R, Andreas Pleil, Nelly
2. Kaulfers AM, Backeljauw PF, Blum S, et al., J Mauras, Judith Ross, Ron Newfield, Lawrence
Pediatr, 2010; (in press).Desai MP, Ogawa M, Silverman, Anja Rohenkohl, Janet Fox and Julia
Yamamoto M et al. Growth Hormone Releasing Quitmann : Health and Quality of Life Outcomes
Hormone Receptor (GHRH-R) gene mutation in (2015) 13:43 DOI 10.1186/s12955-015-0236-2.
familial Growth Hormone deficiency. J Pediatr 9. Jawad, Z and Al- Zubaidi, M, Cause of short
Endo & Metab (2010);13:Suppl 3:1170. stature in patients referred to the pediatric
3. National Center for Educational Statistics. The endocrinology clinic of children welfare teaching
Nation’s Report Card: An Overview of hospital thesis
Procedures for the NAEP Assessment. U.S. 2014.
Department of Education, U.S. Government 10. Al-Saffar, A, Stunting among primary-school
Printing Office; Washington D.C: 2009. NCES children: a sample from Baghdad, Iraq La Revue
2009–493. de Santé de la Mediterranean oriental Department
4. Al Otaibi, M, Al. Issa, S and Omer, H,: Short of Community Medicine, College of Medicine,
stature in children, Pattern and frequency in a 2009, Vol. 15, N° 2.
pediatric clinic, Riyadh, Saudi Arabia, Sudanese 11. AlZubaidi, M, A Saleh M. M. Jawad Z. M. Causes
journal of pediatrics, (2012), 12(1):79. of short stature in Iraqi hospital based study
patients JFac Med Baghdad 2017; Vol.59, No.
5. Grimberg A, DiVall SA, Polychronakos C, et 3
al. Guidelines for growth hormone and insulin- Receive May 2017 Accepted Aug.2017
like growth factor-I treatment in children 12. Moayeri, H and Aghighi, Y, A Prospective Study
and adolescents: growth hormone deficiency, Of Etiology Of Short Stature In Short Children
idiopathic short stature, and primary insulin-like And Adolescents, Department of Pediatrics
growth factor-I deficiency. Horm Res Paediatr. Endocrinology, Med, 2004, 7(1): 23 – 27.
2016;86(6):361-397
13. Lundahl, B. W., Tollefson, D., Risser, H.,
6. Hardin DS. Treatment of short stature and growth & Lovejoy, M. C, A meta-analysis of father
hormone deficiency in children with somatotropin involvement in parent training. Research on
(rDNA origin). Biologics: Targets and Therapy Social Work Practice, 2007, 18, 1-10.
2008; 2(4): 655-61.
14. Rosenfield R, Cuttler L. Short stature. In:
7. Rassheed, S raoof, pattern of chort stature DeGroot LJ Jamesan JL, eds. Endocrinology. 4th
among patients attending the growth center in ed. Philadelphia: WB Saunders; 2001: 485 – 94.
DOI Number: 10.5958/0976-5506.2019.01629.2

The Impact of Smart Phones on Musculoskeletal Pain on

Students in Tikrit University

Firas Tariq Ismaeel

Department of Orthopedics, College of Medicine, Tikrit University, Salah Aldin, Iraq

ABSTRACT
Background: A Smartphone is a device which is can be holded by hand with computer capabilities, such
as internet connections, information storage, video, e-shops, games, and others. Smart phones due its easily
handling has a large impact on everyday life activities.
Patients and Method: current study was done during period (November 2017 to February 2018).to
evaluate the impact of the smart phones on musculoskeletal system among students of Tikrit university,
Total 104 samples( 68 male and 36 female) randomly chosen in cross sectional stud y, data collected by
using self administered questionnaire.
Results of current showed the age of precipitations from (18-26)year. The mean age is 22 ± 4 in study, the
age (18-20 years) is (No.= 32 ; 30.72% ),the age (20-22 years) is the most age included in the study (No.=
40 ; 38.4% ), the age (22-24 years ) is (No.= 26 ; 24.96%) and the age ( 24-26 years ) is (No.= 6 ;
5.76%)also all samples in this study use touch screen smart phone (102 samples), just (2 samples) use
keyboard phones, the duration of use of smart phones during day in the study was high percentage 30.74%(
No.= 32 ) For 2-4 hour followed 22.12% ( No.= 23 ) For 4-6 hour, whilst only ( 15.39 and 12.51) % for
More than 8 hour and hour Less than 2 hour respectively. results of current study showed the males prefer
lay down position during use mobile (61.74% of male ), While female prefer sitting position(55.56% of
female ),as well as 32.34% ( No. = 22 ) prefer sitting position, whilst 25.02% (No. = 9 ) of female prefer
lay down position, as well as
4.41%( No. = 3) of male prefer standing position during use phone while 1.47% (No. = 1) prefer walking,
and 13.89% (No. = 5) of female prefer standing while 5.56% (No. = 2 ) prefer walking, so the 77.9% (No.
= 81) of use social media while 22.1% (No. = 23) not use social media,as well as the Precipitants in study
suffer from neck pain (31.54% ) as highest percentage, followed by wrist pain (25.38) %,but low
percentage (2.31%) for eye pain and joint pain(8.47%).relief pain 38.47% (40 samples ) respondents prefer
rest and also the same number prefer change position while 7.69% (8 samples ) prefer lay down, 1.92% (2
samples ) take pain killer. 13.45% (14 samples) of respondent do nothing to relief pain.
Conclusion: findings of this study is the assessment of effect of smart phones on musculoskeletal system.
Smart phones cause pain mainly in neck joint, wrist joint,back and muscle spasm.The pain increase by
overuse of phones, and relieved by rest or change position.

Keyword: smart phones ; musculoskeletal pain ; students and Tikrit

university

Introduction
Smart phones and musculoskeletal system diseases
attracted the attention of the media and the clinical
literature is being a potential cause for this medical
Corresponding Author: problem(¹). To use the smart phones for sending
Assist Prof. Dr. Firas Tariq Ismaeel messages, Internet searching, or playing games or using
Department of Orthopedics, College of Medicine, other functions, the user usually press on the screen
Tikrit University, Salah Aldin, Iraq repeatedly. These repeated upper-extremity movements
Email: [email protected], in static and bad postures may cause pain, decreases in
[email protected] motor abilities, and feeling of discomfort(²).
554 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 554

Using smart phones for long periods of time well Material and Method
lead to repetitive use of certain group of muscles, which
causes muscle fiber injury, cumulative damage from Cross sectional study was done in Tikrit university.
repeated acute injuries, and myogenic tonus, which the size of sample was ( 68 male and 36 female)(104),
affects mostly often the neck and shoulder muscles (³). age ranged between (17_27)year.Collection of data was
According to study by Shim and Zhu (²), it showed more done by using self administered questionnaire, from
load and stress on neck and shoulder muscles that occur students only. its conducted in Tikrit university from
during the use of touch screen computers and smart students during period November 2017 to February
phones more than the usage of desktop devices. This 2018.randomly assigned and manually analyzed data
occur more easily due small monitors used for tablets, represented by figures and tables in result suction by
smart phones and others. computer using Microsoft excel 2007.
Smart phones usually used in a static positions and
without support to arm and neck well cause abnormal Results
alignment of cervical spine and shoulders. Smart phones
have small monitors, which is usually held during usage,
the users must bend their necks to see the small screens,
this well lead to increasing activity in the neck muscles
especially the extensor group, overloading the neck and
shoulders causing muscle fatigue, decreases muscle
capabilities to work and affects the musculoskeletal
system(2,4).

The mechanical support given by musculoskeletal

system, which is important for providing and permitting
movements, is composed of skeletal muscle, bones,
tendons, cartilages, ligaments and, joints.Skeletal
Figure 1: Distribution of group study according to
muscles contain contractile fibers, and are connected to
gender
the bone by strong attachments through tendons. Bones
act as rigid levers, connecting with other bones through Results in fig.1 showed male (66%) more than
joints, which are kept in relationship by ligaments.as female (34%).
well as a special characteristic of muscle, tendons and
joints is the possession of a rich sensory nerve supply,
which is responsible for detection of position of the body
and the velocity of movement. The integration of this
sensory information by the central nervous system is
important for the musculoskeletal system to act
normally(7).

The main functional characteristics of the bone is

its specialized extracellular matrix, which is hardened
by calcium deposition,enabling it to function as a rigid
lever, The muscles controlling of the head and neck
perform many important tasks, including movement of
the head and neck, swallowing, facial expressions, and
Figure 2: Disruption of study group according to
movement of the eye ball. These actions require strong,
age
forceful movements and one of the fastest, finest, and
delicate adjustments in the entire human body. The Age of precipitations from (18-26)year. The
continuous contractions in the muscles of the neck and mean
upper extremities during usage of smart phones resulted age is 22 ± 4 in study, the age (18-20 years) is (No.= 32
in microscopic damage to the muscles. Repeated press ;
on the screen of smart phones in static position lead to 30.72% ),the age (20-22 years) is the most age included
accumulation of fluids and an increase in compartmental in the study (No.= 40 ; 38.4% ), the age (22-24 years ) is
pressure of muscular tissues(5). (No.= 26 ; 24.96%) and the age ( 24-26 years ) is (No.=
6 ; 5.76%)( fig.2).
Table 1: Duration of using smart phones during day Results in table (2) showed the males prefer lay
Time Number of down position during use mobile (61.74% of male),
% While female prefer sitting position(55.56% of
(hours) Samples
<2 H 13 12.51 female),as well as 32.34% ( No. = 22 ) prefer
2-4 H 32 30.74 sitting position, whilst
4-6 H 23 22.12
6-8 H 20 19.24 25.02% (No. = 9 ) of female prefer lay down position, as
>8 H 16 15.39 well as 4.41%( No. = 3) of male prefer standing position
Total 104 100 during use phone while 1.47% (No. = 1) prefer walking,
and 13.89% (No. = 5) of female prefer standing
In table (1) showed all samples in this study use
while
touch screen smart phone (102 samples), just (2
5.56% (No. = 2) prefer walking.
samples) use keyboard phones, the duration of use of
smart phones during day in the study was high
percentage 30.74%( No.= 32 ) For 2-4 hour followed
22.12% ( No.= 23 ) For
4-6 hour, whilst only ( 15.39 and 12.51) % for More than
8 hour and hour Less than 2 hour respectively.

Table 2: Positions during use smart phones acceding

to gender
Gender
Position Male Female
% %
(No.) (No.)
Lay down 42 61.74 9 25.01 Figure 3: Pie chart show the percentage of use of
sitting 22 32.34 20 55.56 social media in study
standing 3 4.41 5 13.88
walking 1 1.51 2 5.55 In figure (3) appearance the 77.9% (No. = 81) of
Total 68 100 36 100 use social media while 22.1% (No. = 23) not use social
media.

Table 3: Percentage of symptoms in study group

Gender
Symptoms Male (No.) Female (No.) Total ( No.) %
Wrist pain 20 13 25.38
Muscle spasm 13 6 40 14.61
Back pain 16 7 40 17.69
Neck pain 21 20 8 31.54
Eye pain 3 0 2 2.31
Joint pain 11 0 14 8.47
Total 84 46 77 100

In table 3 showed the Precipitants in study suffer from neck pain (31.54% ) as highest percentage, followed by
wrist pain (25.38) %,but low percentage (2.31%) for eye pain and joint pain(8.47%).

Gender
Pain relief by Table 4: Disruption of gender according to Total
relief (No.)
pain
Male (No.) Female (No.)
Rest 30 10 40 38.47
Change position 19 21 40 %
38.47
Lay down 3 5 8 7.69
Drug 2 0 2 1.92
Nothing 14 0 14 13.45
Total 68 39 77 100
To relief pain 38.47% (40 samples ) respondents 3. The relieving factors of pain are take rest, change
prefer rest and also the same number prefer change position and lay down.
position while 7.69% (8 samples ) prefer lay down,
1.92% (2 samples ) take pain killer. 13.45% (14 samples) Recommendations
of respondent do nothing to relief pain( table 4).
1. Decrease duration and frequency of use smart
phone because overuse of phones lead to
Discussion
musculoskeletal system disorder.
The previous studies attempted to investigate 2. Counseling people to have comfortable
whether the use of smart phones is a risk factor that position
would lead to musculoskeletal disorders and examined during use of smart phones.
changes in pain and muscle fatigue occurring during use
of smart phones. 3. Educate people to do special wrist and neck (most
effective parts ) exercises to avoid pain, also
In current study, use of smart phones for long time educate people to avoid abundant use of social
lead to musculoskeletal system disorder. Respondent in media and writing.
this study suffer from neck pain, wrist pain, back pain,
muscle spasm, joint pain and eye pain, These results Ethical Consideration: All the participants will not be
were consistent with the results of other previous studies subjected to harm in any way, as well as Precipitants in
that show pain in the neck and shoulders due to use of research will take full privacy for their answers, so the
smart phones the results of a study by Berolo etal.,(¹) research is clear from any misleading information, also
Also, it was reported that the use of smart phones caused any representation of primary data findings in a biased
pain in users’ necks, shoulders, and arms. Fischer(5), way is avoided.
Wrist pain is one of the findings in this study (33
Source of Funding: Self
samples) and this is also was mentioned in previous
study that show the intensive use of the hands,thumbs, Conflict of Interest: Nil
and fingers with repeated, static, or extreme finger
postures may lead to pain and discomfort, Wrist pain
REFERENCES
may indicate development of carpal tunnel syndrome so
that, these cases need to undergo further investigations 1. Berolo S, Wells RP, Amick B.C.Musculoskeletal
to confirm the diagnosis(6,7,8). symptoms among mobile hand-held device users
and their relationship to device use. Appl
The respondents suggest that pain due to use of
Ergon
phones can be relieved by rest or change position. Also,
211;42: 371–378.
some of respondents prefer lay down to relief pain.
Some of them take pain killer. But, about 13.45% of 2. Shin G, Zhu X.User discomfort, work posture
sample do nothing to relieve pain. This show in table 4. and muscle activity while using a touchscreen in a
In this study the questionnaire is self administrated, so desktop PC setting. Ergonomics 2011; 54: 733–
that chance of bias increased. 744.
3. Schüldt K, Ekholm J, Harms-Ringdahl K.(1986).
Conclusion
Effects of changes in sitting work posture on static
1. Current study conclude the effect of smart phones neck and shoulder muscle activity. Ergonomics
concentrated on wrist and neck joints. Also, other 1986;29: 1525–1537.
parts affected like back,muscle spasm and eye
problems,this effect is increase with increase use 4. Mekhora K, Liston CB, Nanthavanij S.The effect
of phones. of ergonomic intervention on discomfort in
computer users with tension neck syndrome. Int J
2. Signs and symptoms due to the use of smart
Ind Ergon 200; 26: 367–379.
phones include : neck pain, wrist pain, back
pain,muscle spasm, eye problems and other joints 5. Diulian Muniz Medeiros; Rodrigo Freitas
pain. Mantovani ; Cla´udia Silveira Lima.Effects of low-
intensity pulsed ultrasound on muscle thickness
and echo intensity of the elbow flexors
following
exercise-induced muscle damage. Sport Sci Health 8. Juleen R Zierath and John A Hawley.Skeletal
2010;DOI 10.1007/s11332-017-0366-5 Muscle Fiber Type: Influence on Contractile and
6. Fisher AA. Documentation of myofascial Metabolic Properties. PLoS Biol.2004; 2(10):
trigger e348.doi: 10.1371/journal.pbio.0020348.
points. Arch Phys Med Rehabil 1998; 96: 286– 9. Pirko, E. Y.; Razooqi,B.M.and Salman, H.K.
291. 22. and Tektook, N.K.Bacterial isolate isolated from
7. Fontana L, Neel SC, Ughetto JM.Osteoarthritis of Mobile Medical Staff of Immam Ali Hospital –
the thumb carpometacarpal Joint in women and Baghdad. 2nd international conference ;2018.
occupational risk factors: a case–control study. J
Hand Surg Am. 2007; 32: 459–465.
DOI Number: 10.5958/0976-5506.2019.01630.9

Risk at the Educational Laboratory in Indonesia

Frida Qurbasari D.1, Putri Ayuni Alayyannur1, Dani Nasirul Haqi1, Meirina Ernawati1, Fauziah Mukti
Sugiharto1
1
Department of Occupational Safety and Health, Faculty of Public Health Universitas Airlangga,
Surabaya 60115, East, Java, Indonesia

ABSTRACT
A laboratory of Audio-Visual Aids (AVA) at the Faculty of Public Health of Universitas Airlangga is one
of the education laboratories used as a room for teaching and learning activity related to health promotion
implementation and behavioral science that becomes one of the competencies of public health graduates.
Laboratory of AVA is equipped with electronic devices, storage cabinets, desks, chairs, and other supported
equipment used for the laboratory work that has potential hazards and it can cause risks and impacts. In
addition, it can damage either the students or the educational institution if the control is not performed. The
objective of this research was implementing the method of Hazards Identification, Risk Assessment, and
Determinant control at the Laboratory of AVA as a control effort toward the available potential hazards.
The variables of this research were Hazard Identification, Risk Assessment, and Determinant control.
Based on the finding toward hazard identification that had been done, it had been collected 6 activities that
could lead to hazard potential and 7 sources of hazard that could cause 8 risks of occupational health and
safety. Risk Assessment that had been done toward the available 8 risks, there were 7 risks included in low-
risk level and
1 risk was included in moderate risk level. The given recommendation was tidying up the electrical cable
installation, providing warning signs, repairing the broken or opened window, the lectures or teaching staffs
guide the students to use a proper editing method, repairing the position of LCD and projector display, and
providing the First Aid Kits and its content.

Keywords: risk assessment, HIRADC, laboratory

Introduction are used for supporting the work activity. The devices
and technology used for working can give the employees
Occupational health and safety according to OHSAS
an impact in form of the risk of occupational accident,
18001:2007 is a condition and a factor that has a potential
damage, and occupational disease.
towards the health and safety of the workforce and other
employees comprising contractual employee, contractor In ILCI theory i.e. Loss Causation Model, it is
personnel, or other people in work environment(1). Work mentioned that there are two causes of occupational
environment or workplace according to Law Number 1 accident i.e. the basic cause and direct cause. The
the Year 1970 is any room on space or field, it is closed underlying cause of the occupational accident is the
or open, moving or stationary for the place for the human factor and occupational factor. The human factor
employee to work, or it is often used by the employees that can cause occupational accidents including lacking
for a business and the place where the sources of hazard physical, mental, and psychological capabilities, lacking
exist(2). The potential hazard that is available in the knowledge and skill, stress, and inadequate motivation.
workplace can occur from the use of various devices and Meanwhile, an occupational factor is an environmental
technology that condition that does not really support the employee to
do their job safely. The direct causes of the occupational
accident are unsafe action and unsafe condition (3).
Corresponding Author:
Putri Ayuni One of the controls against the potential hazard is by
Alayyannur conducting the management of the risk of occupational
Department of Occupational Safety and Health, health and safety. According to Ramli, the process of
Faculty of Public Health Universitas Airlangga, risk management is one of the steps that can be
Surabaya 60115, East, Java, Indonesia done
Email: [email protected]
559 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 559

for realizing a sustainable improvement(4). This risk promotion and behavioral science that become one of
management process should be done comprehensively the competencies of public health graduates. The
and it should be a part that is not separated from the laboratory of AVA at the faculty of Public Health is
management process. The processes included in the equipped with electronic devices, storage cabinet, desks,
Risk Management Standard AS/NZS 4360 (2004) chairs, and other supporting devices that are used for
are (1) determining the object and the scope of the laboratory work activity.
risk management implementation, (2) implementing
risk identification, (3) conducting the risk assessment The objective of this research was implementing
consisting of risk analysis for determining the possibility Hazard Identification, Risk Assessment, and
and the consequence that will happen, determining the Determinant control (HIRADC) method at the
priority scale and comparing the available criteria, Laboratory of AVA as a preventive effort toward the
(4) conducting the risk evaluation to determine the accident and disease due to the use of the laboratory.
priority scale and comparing the available criteria, (5)
conducting an unacceptable Determinant control, (6) Material and Method
conducting the communication and the consultation
that are performed in risk management process, which The research was conducted at the Laboratory of
involves all parties, and (7) determining the monitoring AVA Faculty of Public Health of Universitas Airlangga,
and review toward the risk management program that Surabaya. This research was an observational
has been implemented. The overall process of risk descriptive with a cross-sectional approach. The
management can be called Hazard Identification, Risk data used in this research was the primary data
Assessment, and Determinant Control (HIRADC)(5). collected using an observation method.

Universitas Airlangga is a pedagogical institution The primary data was collected for identifying the
that extremely supports the teaching and learning physical and common hazards comprising (1) dust, (2)
process performed by the lectures and the students noise, (3) being hit by falling objects, dan (4) the danger
so that they put their best effort in providing the of electricity. The data collection was done with the
supporting infrastructures and facilities for teaching and assistance of observational table to identify and assess
learning activity. One of the supporting infrastructures the danger related to the occupational accident. The
and facilities for teaching and learning activity is an assessment toward the hazards was done by combining
educational laboratory in form of a Laboratory of the values of likelihood and severity to find out the
Audio-Visual Aids (AVA) existed in the Faculty of collected risk level. Thereby, the appropriate Determinant
Public Health. Laboratory of AVA in the Faculty of control could be done. The data that had been collected
Public Health is functioned as a place for conducting a was then being processed in a matrix and descriptive
learning process related to the implementation of health forms and it was also presented in narrative form.

Findings
Table 1: Hazard Identification and Risk Assessment at the Laboratory of Audio-Visual Aids of the Faculty
of
Public Health of Universitas Airlangga

Risk Assessment Matrix

Activities Sources of Hazard Risks
L S RR
Using the Electricity Electricity current Electrical Shock 2 2 4 (Low)
source as the support for Tripping over electrical cable
learning activity Electricity cable 3 1 3 (Low)
installation
Inhaling dusty air 1 1 1 (Low)
Dust in the room for The available things in the
storing works room for storing works can be 1 1 1 (Low)
General lecturing activity easily dirty and broken
The dangerous
Being hit by falling LCD and
position of LCD and 1 2 2 (Low)
Projector
Projector Display
Conted…

The lecturing activity in Properties Being hit by falling properties 1 2 2 (Low)

Foundation of
Communication Media, Noise (Intermittent noise-induced hearing disorder,
3 1 3 (Low)
Information, and Education Noise) stress
The laboratory work
implementation/learning The injury cannot be treated by
No First Aid Kit at the 6
activity at the laboratory first aids and it can result in 2 3
laboratory (Moderate)
of AVA and the incident of severe injury
minor accidents
Hazard Identification: The hazard identification that become easily dirty and broken. Thereby, it could not be
was done at the Laboratory of AVA by observing the seen and learned by the visitors of the room for storing
devices, activities, and the environment of each activity. works. The activity of general lecture that had a
The best approach used for identifying the hazard was a potential hazard was the position of LCD and the
proactive approach since it could found out the hazard projector display that was dangerous. LCD and projector
prior to causing the impact. According to Ramli, without display available at the Laboratory of AVA was placed
recognizing the hazard, the risk could not be determined on the ceiling of the laboratory in hanging position. The
so that the control effort toward the risk could not be position could make people around the LCD and
implemented(4). One of the proactive approaches that projector display in danger since the object in a hanging
could be used for identifying the risk was Job Safety position was vulnerable to cause people to be hit by
Analysis (JSA) that was conducted at each available falling objects.
work activities.
The third potential hazard was from one of the
The first potential hazard was from the activity of lecturing activities such as Foundation of
using electricity source as the support for the learning Communication Media, Information, and Education.
activity. The activity had some sources of hazard i.e. the Those courses had some outputs in form of making
high electric current that risked the people around the visual, audio, and audiovisual media and conducting
source of hazard to get an electric shock and the use of the display of audio-visual media as the final project
an electrical cable that was not organized well could risk conducted at the Laboratory of AVA. The final
people around the source of hazard to be tripped over project needed some properties used for decorating the
the electrical cable installation that was being used. The laboratory so that it became a proper room according to
use of electricity source in the learning activity at the the students’ needs. The use of the properties needed
Laboratory of AVA was the primary thing that should some lifting and transporting processes that needed
be done to support the learning activity since learning more than one lifting process, and the installation of
activity needed a media such as LCD, projector, and the properties at the laboratory. It would result in the risk
speaker for the lectures in conveying the course of being hit by falling properties due to the lifting and
material. transporting processes and the incorrect installation of
the properties. In addition, the learning process of
The second potential hazard was from the activity Foundation of Communication Media, Information, and
of general lecture i.e. the room for storing works used Education had other potential hazards such as
for storing the students’ works after conducting the momentary noise or intermittent noise. This momentary
laboratory work on health promotion and behavioral noise happened when the process of presenting the
science. The room for storing works was rarely visited final project occurred since it needed the speaker for
by the students, lectures, teaching staffs or the laboratory the presenter to communicate with the audiences who
officer and it caused the room for storing works was watched the presentation. Besides requiring the speaker
rarely cleaned so that there was so much dust stuck on to communicate the presentation, another media used
the students’ works. The dust sticking on the works here for supporting this final project presentation was
might be inhaled by people who visited the room for the speaker for music or video presented in the final
storing works. Besides, the dust could make the project. This momentary noise could cause noise-
students’ works induced hearing disorder and stress
in the students, lectures, teaching staffs, and laboratory respiratory irritation due to inhaling the dust, the
officers. The project presentation of Foundation of students’
Communication Media, Information, and Education was
conducted 3 times in a week for 7 weeks consecutively.

The fourth potential hazard was from the activity of

general lecture or the laboratory work implementation at
the Laboratory of AVA. The laboratory work activity or
general lecture conducted at the laboratory had a risk at
each activity process. The available risk could cause
both small and major injuries that needed the first aid.
At the Laboratory of AVA, there was no First Aids
equipment so that when the injury happened due to the
general lecturing activity or laboratory work
implementation at the laboratory, it could not be treated
immediately. It is not in line with the regulation of
Ministry of Manpower and Transmigration of the
Republic of Indonesia Number
15 the Year 2008 on First Aid in the workplace; it is
stated that each institution should provide the First Aids
facilities and the officer. According to the Regulation
of Ministry of Manpower and Transmigration of the
Republic of Indonesia Number 15 the Year 2008, First
Aid in the workplace is the attempt to provide accurate
and immediate first aid to the employees/labors and/or
other people in the workplace who are sick or injured.
The Laboratory of AVA is the workplace for the
lectures, teaching staffs, laboratory officers, and the
place for the students to study and apply their
knowledge.

Risk Assessment: AS/NZS 4360: 2004 explains that the

risk can be found through a combination between the
severity of risk impact and likelihood and the possibility
of the occurrence of the risk(5). The assessment using
the combination between severity and likelihood was
used for determining the risk level whether it was low,
moderate, or severe.

The result of risk assessment at the Laboratory of

AVA found that there were 7 risks out of 8 risks in low
level and 1 risk in the moderate level that can be seen in
table 1. The risk in moderate level was the injury that
could not be treated using the first aids and it resulted
in severe injury due to unavailability of First Aids
Kits at the Laboratory of AVA. According to
AS/NZS
4360:2004, the risk level in the moderate category does
not need the top management involvement, but it needs
immediate treatment action to reduce the risk(5).

Meanwhile, the risks in low category were electrical

shock, tripping over the electrical cable installation,
works could be easily dirty and broken so that they could
not be seen and learned by the visitor of the room for
storing works, being hit by falling properties, being hit
by LCD and projector display, and noise-induced hearing
disorder and stress due to the momentary noise.
According to AS/NZS 4360: 2004, the risk level in the
low category could be treated using an applicable regular
routine(5).

Determinant Control: Determinant control is an

important step and it determines the overall risk
management.. According to OHSAS 18001: 2007, the
Determinant control attempt should be done to prevent
and reduce the prevalence of occupational accident and
damage; the effectiveness of control should be assessed
to know how far the control had been conducted to be
able to eliminate or minimize the available potential
hazards(1). Tarwaka explains that the hierarchy of
Determinant control as the procedure that should be
considered when choosing a method to reduce or
decrease the risk such as elimination, substitution,
technical engineering, administrative engineering, and
the use Personal Protection Equipment (PPE)(6).

The Determinant control efforts that were available

at the Laboratory of AVA had been conducted based
on the available risk were tidying-up the electrical
cable installation, hanging curtains on the broken
window to minimize the dust from entering the room,
providing warning signs, setting up the intensity of
sound, supporting the LCD for a temporary period of
time, and curing wounds using the available equipment.
From variable Determinant controls that had been done
at the Laboratory of AVA, there was still some risks in
that the risk category should be degraded so that the
researcher recommended some Determinant controls
comprising fixing the opened or broken window in the
room for storing works, the lectures, teaching staffs,
or the laboratory officers guide the students to use the
proper editing method, fixing the position of LCD and
projector display in a safety place, and providing the
first aid kit and its content according to the Regulation
of the Ministry of Manpower and Transmigration of the
Republic of Indonesia Number 15 Year 2008 on First
Aid in the workplace(7).

Conclusions

The hazard identification that had been done against

the activity done at the Laboratory of Audio-Visual Aids
of Faculty of Public Health of Universitas Airlangga,
it had been collected 7 potential hazards from all
work
activities that could cause 8 risks related to occupational REFERENCES
health and safety.
1. OHSAS 18001. Occupational Health and Safety
The result from the risk assessment done at the 8 Management System Requirements. 2007.
risks, it had been obtained 2 risk levels i.e. 7 risks in 2. House of Representative (Republic of Indonesia).
low category and 1 risk in the moderate category. The Law Number 1 about Occupational Safety.
teaching staffs and the officers of the Laboratory of AVA Jakarta; 1970.
had performed some initial control efforts to minimize
the available risks. The recommendations that could be 3. Sugandi D. Anthology of Company Hygiene and
given to prevent and minimize the impact that could Occupational Safety : Use of Personal Protective
be caused by the available risks were tidying-up the Equipment for Workers. Semarang: Universitas
electrical cable, providing warning signs, repairing the Diponegoro Publisher; 2016.
opened or broken window, the lectures or teaching staffs 4. Soehatman Ramli. Practical Guidelines for Risk
guide the students to use the proper editing method, Management in the Occupational Health and
fixing the position of LCD and projector display and Safety OHSAS 18001 Perspective. Jakarta: PT.
providing the first aids kit and its content. Dian Rakyat; 2010.
Etichal Clearance: Etichal Clearance is taken from 5. AS/ANZ 4360. 3rd Edition The Australian And
Health Research Committee, Faculty of Public Health, New Zealand Standard on Risk Management.
Universitas Airlangga Indonesia. Australia; 2004.

Source of Fundings: The author(s) disclosed receipt 6. Tarwaka. Occupational Health and Safety.
of the following financial support for the reasearch, Surakarta: Harapan Press; 2008.
authorship, and/or publication of this article. This study 7. Ministry of Manpower and Transmigration
was supported by Universitas Airlangga. (Republic of Indonesia). Regulation of Minister of
Manpower and Transmigration Number 15 about
Conflicts of Interest: Nihil
First Aid in Workplace Accidents. Indonesia;
2008.
DOI Number: 10.5958/0976-5506.2019.01631.0

Split Face Comparative Study of the Efficacy and Outcome

of ND: YAG Laser and Intense Pulsed Light System for Hair
Removal

Haider Al-Sabak1, Muhsin Al-Dhalimi1, Eman Mohammed2

1
MD, University of Kufa, Faculty of Medicine, Iraq, Dermatology; 2MD, Al-Qhadisia Health Directorate,
Iraq, Dermatology

ABSTRACT
A prospective clinical split face comparison study conducted to compare the efficacy and safety of long-
pulsed Nd:YAG laser and IPL in the treatment of idiopathic facial hirsutism. A 42 females with idiopathic
hirsutism aged16-52 years with skin types II–IV were enrolled. A 38 patients completed the study; IPL
applied on the right sides of the face and the ND: YAG on the left sides. They underwent six treatment
sessions with 4 weeks intervals. Findings revealed that IPL treatment resulted in longer median hair-free
intervals than Long-pulsed Nd:YAG laser therapy. Decrease in hair counts was significantly higher after
IPL than Long-pulsed Nd:YAG laser. Hair reduction was 40%, 69% and 86% on IPL versus 32%, 58% and
80% on Long-pulsed Nd:YAG laser (p=0.0001), respectively. Patient satisfaction scores were significantly
higher for the IPL when compared with Long-pulsed Nd:YAG laser treated sides at 1, 3, and 6 months.
Slight stinging and burning sensation at time of the treatment were recorded in all patients. Erythema was
seen on both the treated sides in all cases, which lasted from hours up to 2 days after session. Only 4
patients develop Leukotrichia on IPL treated side and are felt to be due to thermal damage to the
melanocytes.

Keywords: Hirsutism, Idiopathic, treatment, ND: YAG Laser, Intense Pulsed Light
System

Introduction The longer Nd: YAG laser wavelength provides deeper

penetration, a necessary factor in the attempt to achieve
Hirsutism is defined as excess growth of terminal
optimal laser hair removal results. In addition, the 1064
(coarse, medullated) hair in a female in a typically male
nm wavelength is relatively less absorbed by epidermal
distribution1. The androgen dependent growth areas
melanin than are the 694 to 810 nm wavelengths8.
affected include the upper lip, cheeks, chin, central
chest, breast, lower abdomen, and groin2. The term
idiopathic hirsutism has been used to describe the Patients and Method
circumstance in which hirsutism is present with This is a therapeutic interventional split face
circulating androgen levels within the normal range 4. comparative study of the efficacy and outcome of
Laser hair removal is accomplished through follicular Nd:YAG laser and an intense pulsed light system for
unit destruction. The ability to remove hair without treatment of idiopathic hirsutism. It was conducted at the
damaging the surrounding skin is based on selective Laser Research Unit, College of Medicine, University of
photothermolysis. Lasers or light sources with Kufa; for the period from October 2016 to October
wavelengths of about 600–1100 nm are absorbed by 2017. The ethical approval was obtained from the
melanin and well suited for hair removal6,7. Scientific Council of Dermatology and Venereology -
Iraqi Board for Medical Specializations. Forty two
females were enrolled in this study; four of them
Corresponding Author: defaulted; because of the treatment was interfered with
Haider Al-Sabak their work. Thirty eight patients completed the
MD, University of Kufa, treatment, of skin types II–IV. Hormonal assays
Faculty of Medicine, Iraq, Dermatology including follicle stimulating hormone (FSH),
Email: [email protected] luteinizing hormone (LH), serum
564 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 564

testosterone, dehydroepistenedione sulphate (DHEAS), IPL. The patients were also instructed to shave the area
serum prolactin, serum fasting insulin, and abdomino- to be treated immediately before therapy to minimize the
pelvic ultrasonography were done to diagnose any side effects that result from burning and smarting of the
hormonal abnormality. Any patients with a suspected hair and to reduce energy absorption by hair shaft. No
hormonal causes hirsutism were excluded. Only patients local anesthesia of any kind was required.
with idiopathic hirsutism were included. Formal consent
was taken from each patient after full explanation Evaluation: All the patients were evaluated objectively
about nature of study. Exclusion criteria were pregnant and subjectively regarding their response to the
women, patients with a history of keloid scars, light treatment by the following methods:
sensitivity and using systemic medications known to be Objective Methods:
photosensitizing.
1. Photographic assessment: Color photographs for
This study was a split-face controlled trial of facial each patient were performed at the baseline and at
hair removal comparing the long pulsed alexandrite laser 1,
(Quanta system, ITALY) with the IPL system (Quanta 3 and 6 months of treatment. Frontal, right and left
system, ITALY). Patients with skin type’s II–III were side of face views were taken using Sony- Digital,
treated using 11 J/cm2 as a starting fluence increasing high sensitivity, 8 mega pixels, DSC-W30 still
up to 15 J/cm2 as tolerated, with double pulses and a camera, in the same place with fixed illumination
pulse duration of 20 milliseconds. Those with skin type and distance. All the treated patients were assessed
IV were started at 10 J/cm2, increasing to 13 J/cm2 as at the end of the study in computer view, blindly
tolerated. The Quanta ND: YAG laser (Quanta by two independent board certified dermatologists
system by visual analogue scale (VAS) of improvement
- DNA laser technology – ULTRALIGHT, Milan, Italy) by scale scores from 0 to 10.
used in this study has a wavelength of 1064 nm and 25
2. Hair-free intervals (HFI): HFI in days were
milliseconds pulse duration. All patients were treated
recorded following each treatment. HFI were
using 10 mm spot size, 25 milliseconds pulse duration
defined as the time to first hair re-growth, as
and accompanying Dynamic Cooling Device. Standard
measured by the patient, following each
starting fluence of 48 J/cm2 was used, with fluence
treatment.
subsequently increased up to 55 J/cm2 as tolerated. After
explaining the procedure to the patient, the patient was 3. Hair Density: The numbers of hairs in (4cm2
instructed to lie on a comfortable couch, under good area) square were calculated, for this a square
light, goggle was worn by the patient, a transparent color was drawn on skin with colored pen in fixed area
gel applied to the area to be treated. The patients divided on each side of the face for each patient. Digital
randomly in to two groups, one group applied IPL on the camera (Sony, 8 Mega Pixels) was used to take
right sides of the face and the ND: YAG on the left sides photograph of this area.
and the other group vice versa.
Subjective Methods, Which Include:
All areas were treated in a sequence with minor
1. Patient’s satisfaction: Patient satisfaction
overlap in adjacent areas. The fluence was increased
questionnaire with laser treatment in terms of
gradually when the patient tolerate the pain. The patient
hair reduction was recorded on linear analogue
was instructed to avoid sunlight for the next two days.
scales (LAS) with 0 = not at all satisfied and 10 =
The next visit was scheduled 4 weeks later. The patient
extremely satisfied.
was told to record any side effects or to call the doctor
if she needed. The patients underwent six full treatments 2. Side Effects: Any incidence of immediate or
with 4 weeks intervals between treatments. Response to delayed complications was assessed and recorded
treatment on the both sides of the face was at each visit, including: erythema, stinging pain,
assessed at hypo/hyper pigmentation and blistering.
1, 3 and 6 treatment sessions. Patients were instructed
that they should not epilate the hair from the area to Statistical Snalysis: Statistical analyses were done
be treated for at least two weeks before each session, through descriptive and analytic statistics by using
because epilation will remove the hair follicle with its scientific calculator and SPSS version 10 considering
melanin content; which is the target for the laser P-value of ≤ 0.05 as significant.
and
Findings of Hair–free intervals between the IPL and
Nd:YAG laser sides, 5.79 ± 4.2 and 5.95 ± 5.19
The patients’ age ranged (18-50) years. And patients
respectively, (p=0.7), (Table 1).
in both groups were almost matched for age, diseases
duration and other demographic characteristics 3. Hair Density: A gradual decrease in hair density
with the increase in number of sessions was
Objective Method: shown from pretreatment until sixth session.
1. Photographic Evaluation: According to visual There was no difference in pretreatment hair
assessment of hair reduction on each side of the density between IPL and Nd:YAG laser sides,
face for each patient by computer viewing of their given a mean ± SD of 50 ± 21.6 and 41 ± 21.1
photographs before and after treatment by using respectively p=0.998 (Table 2).
visual analogue scale.
Subjective Evaluation, Which Included:
At the end of the study, the visual analogue scale
1. Patient’s satisfaction: At all stages of follow-
(VAS) at IPL system and Nd:YAG laser treated
up, patient satisfaction with IPL treated side was
sides were 7.3 ± 1.2 and 6.5 ± 1.2 respectively, P
statistically highly significant P value=0.0001,
value=0.0001 (highly significant).
(Table 3).
2. Hair–free intervals (HFI): A gradual increase in
2. Side effects: Slight stinging pain at time of
time of HFI with the increase in the number of
treatment was recorded in most patients (Table 4)
sessions was shown from pretreatment until sixth
in women with idiopathic hirsutism.
session. There was no difference in
pretreatment

Table 1: Mean and Standard Deviation (SD) of hair free interval

Comparison between pretreatment and first session

Pretreatment First session
System type Difference P value Increased%
mean ± SD mean ± SD
IPL 5.79 ± 4.2 13.08 ± 4.2 7.3 0.0001 126%
Nd:YAG 5.95 ± 5.19 9.05 ± 4.25 3.1 0.0001 52%
Comparison between pretreatment and Third session
Pretreatment Third session
System type Difference P value Increased%
mean ± SD mean ± SD
IPL 5.79 ± 4.2 19.16 ± 5.2 13.4 0.0001 231%
Nd:YAG 5.95 ± 5.19 13.4 ± 5.08 7.5 0.0001 126%
Comparison between pretreatment and sixth session
Pretreatment sixth session
System type Difference P value Increased%
mean ± SD mean ± SD
IPL 5.79 ± 4.2 28.89 ± 8.497 23.1 0.0001 554%
Nd:YAG 5.95 ± 5.19 19.95 ± 8.99 14 0.0001 235%
The statistic of hair free interval (P. values)
between pretreatment (laser-IPL) 0.700
between 1 session (laser - IPL)
st
0.0001
between 3rd session (laser - IPL) 0.0001
between 6 session (laser - IPL)
th
0.0001
Table 2: Mean and Standard Deviation (SD) of Hair density

Comparison between pretreatment and first session

Pretreatment First session
System type Difference P value Reduction%
mean ± SD mean ± SD
IPL 50 ± 21.6 30.3 ± 15
Nd:YAG 41 ± 21.1 27.8 ± 14.4 13.2 0.0001 32%
Comparison between pretreatment and Third session
Pretreatment Third session
Difference P value Reduction%
mean ± SD mean ± SD
IPL 50 ± 21.6 15.4 ± 11.6 34.6 0.0001 69%
Nd:YAG 41 ± 21.1 17.1 ± 11.6 23.9 0.0001 58%
Comparison between pretreatment and sixth session
Pretreatment sixth session
Difference P value Reduction%
mean ± SD mean ± SD
IPL 50 ± 21.6 7.2 ± 8.4 43.2 0.0001 86%
Nd:YAG 41 ± 21.1 8.3 ± 7.5 32.5 0.0001 80%
The statistic of hair density (p-values)
between pretreatment (laser - IPL) 0.998
between 1st session (laser - IPL) 0.252
between 3 session (laser - IPL)
rd
0.433
between 6 session (laser - IPL)
th
0.376
Table 3: Comparison between Nd:YAG and IPL Discussion
regarding satisfaction (N = 38)
Unwanted hair growth remains a therapeutic
System type challenge and there is a need for an effective, safe, and
Session Nd:YAG IPL P value non-invasive treatment modality capable of removing
Mean ± SD Mean ± SD hairs on a long term basis 3.
First 2.3 ± 1.1 5.6 ± 2.3 0.0001
In the present study we conducted a split-face
Third 2.5 ± 1.3 7.5 ± 2.7 0.0001 comparison for treatment of hirsutism with Long-pulsed
Sixth 2.5 ± 1.2 8.3 ± 3.1 0.0001 Nd:YAG laser 1064 nm and Intense Pulsed Light
System
650-1200 nm in women with idiopathic hirsutism.
Table 4: Side effects in Rt. and Lt. Sides after
(1, 3, 6) Session The result from this study was that IPL treatment
resulted in longer hair-free intervals than Long-pulsed
Nd:YAG laser therapy (At sixth session HFI was
System Session no. increased to (55.4%) on IPL versus (23.5%) on Long-
Side effect Total
type 1 3 6 pulsed Nd:YAG laser) p-value = 0.0001.
Nd:YAG 0 0 0 0
Hyperpigmentation Hair reduction was 86% on IPL versus 80% on
IPL 2 6 0 8
Long-pulsed Nd:YAG laser at 6 months duration. When
Nd:YAG 0 0 0 0 compared between IPL and ND: YAG at sixth session
Burning pain
IPL 2 4 2 8 p=0.376 finding was statistically not significant.
Nd:YAG 10 3 0 13
Erythema Patient satisfaction scores were significantly higher
IPL 25 10 5 40
for the IPL when compared with Long-pulsed Nd:YAG
Nd:YAG 0 0 0 0 laser treated sides.
Swelling
IPL 1 2 0 3
Kamal et al.200611, reported that 20% of patients on
Nd:YAG 0 0 0 0
White hair Nd:YAG laser and 30% of those on IPL device exhibited
IPL 0 3 4 7 excellent hair reduction.
Karaca et al.2012, recorded in Comparison of SHR pigmentation, duration of the hair follicle cycle, and
Mode IPL System with Alexandrite and Nd:YAG Lasers androgen status 16. In this study the two used devices
For Leg Hair Reduction, that the mean hair reductions were compared in the same subject, at the same
in 6 weeks after three sessions were 50% for the IPL anatomical site and at the same time, so, differences in
system, 53% for Alexandrite and 39% for the Nd: YAG efficacy could be attributed to laser variables and not to
lasers. However, after 6 months; 40%, 49% and 34% the subject.
hair reduction were observed, respectively (12). This study
was comparable with the present study as the IPL has The present study is comparing between the
higher hair reduction than Nd:YAG laser but statistically treatments with long-pulsed Nd:YAG laser and IPL,
not significant. results revealed that both modalities were effective
in hair reduction. These results are expected because
AL-Hamamy et al.2015, Compared in a split-face the mechanism of action of laser and IPL is the same
study the effectiveness of diode laser 808 nm and the (destruction of stem cell in hair bulge by the heat
IPL (690 – 1200 nm) in treatment of hirsutism. Results produced by the absorption of light energy in
revealed after three sessions that both modalities were melanosomes).
effective in hair reduction. For diode laser hair density
was decreased by 30%, 45% and 58% compared with Conclusion
IPL in which the hair density was decreased by
38%, Both Long-pulsed Nd:YAG laser and IPL were
44% and 49% after the first, second, and third effective in unwanted hair removal. However;
session, prolongation of the time for hair regrowth were
respectively .
13 significantly higher with IPL system.

Recently Neejra 14, reported in comparative study Ethical Clearance: All ethical issues were approved
between Diod, Nd:YAG lasers and IPL, the percentage from the local committee of ethical issues for scientific
of hair reductions after eight sessions were 92%, 90% researches.
and 70% respectively. This result differs from that of
Conflict of Interest: None.
the present study as IPL in this study have lower hair
reductions than Nd: YAG laser. Source of Funding: Self-Funding

Radmanesh et al 15. Investigated the side effects

of IPL used for hair removal among 1,000 female
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at the time of treatment was recorded in most patients. Endocrinology, March 2009; 25(3): 140–148.
Erythema was seen on both treated sides, which lasted
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DOI Number: 10.5958/0976-5506.2019.01632.2

C-reactive Protein and its Relationship with Lipid Profile in

Suicidal and Non Suicidal Adults with Major Depression

Hassam M. Al-Amarei1, Suaad Mohammed H. Rasheed2, Ali J. Eidan3

1
M.Sc. Mental Health Nursing, Faculty of Nursing, 2Ph.D. Medical Microbiology, Faculty of Medicine,
3
Ph.D. Basic Medical Science, Faculty of Nursing, University of Kufa, Iraq

ABSTRACT
Objectives: We tested whether C-reactive protein and lipid profile might be associated with suicide
attempts
in subjects with major depressive disorder, after controlling for relevant individual characteristics.
Design And Method: Plasma levels of C-reactive protein and lipid profile; as well as Total Cholesterol
(TC), and Triglyceride (TG), were determined in 60 patients meeting DSM-IV criteria for Major
depression (22 suicidal attempters and 38 patients without suicidal behavior), and 30 healthy controls.
Study participants were evaluated using Hamilton Depression Rating Scale and the Beck’s Suicidal
Ideation Scale.
Results: At univariate analyses, plasma level of C-reactive protein was significantly higher in suicide
attempters (SA) than non-suicidal attempter depressed patients (NSA) and healthy control (p<0.05), while
the plasma level of TC among SA were significantly lower than those NSA or healthy control subjects
(p<0.05). Also, TG level was significantly higher in both SA and NSA (p=0.009 and p<0.001 respectively)
compared with healthy control. After adjustment of potential confounders, suicide attempters were still had
significantly lower levels for TC than NSA.
Conclusions: Our findings support the hypothesis that CRP, and TG are associated with suicide attempts
in patients with major depressive disorder. The identification of valid and accessible biological markers of
suicidal behaviors still represents a challenge for future research.

Keywords: Depression, Suicide, CRP,

Lipid
Introduction Among the underlying biological changes, accumulating
studies indicate that a dysregulated immune system
Suicide is a significant public health issue and a
could be a contributing factor to depression, and
major cause of death throughout the world 1. In Iraq, the
possibly specifically to suicidality 3.
suicide rate is a current health problem exacerbated by
the fact that it is a country suffered war and destruction One possible pathway implicating the immune
in all fields of life. Although most of Iraqi people are system is through the action of inflammatory cytokines,
Muslim and Islam forbids suicide, it has presented an signaling molecules that mediate important steps in
increase in its suicide rate. For example, between 2015 humoral and cellular immunity and that can cross
and 2018 there was an increase in the suicide rate from the blood brain barrier and influence complex brain
1.09 to 3 cases per 100,000 inhabitants 2. This is a functions4.
worrying and alarming phenomenon need to strategies
Due to the short half-life of cytokines, CRP
of prevention.
is a relevant alternative for research to focus on
interrelationships between inflammation and suicide
Corresponding Author: because of its long half-life and detectability at lower
Ali J. Eidan levels. CRP is an acute-phase inflammatory protein
Basic Medical Science, Faculty of Nursing, synthesized by hepatic Kupffer cells signaling other
University of Kufa, Iraq body cells for destruction by the complement system
Phone: 00964 780 182 1063 and generated in response to increases in serum IL-
Email: [email protected] 6
570 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 570
5
. Several studies have assessed CRP levels in patients men and 14 women) were recruited during the
with suicidality, with contradictory results 5-8. One of consultations in the Department of Psychiatry,
these studies was designed an inflammatory index, Al-Hakeem Hospital. Mean age of the patients
consisting of CRP, IL-6, IL-10 and TNF-α, in patients were 30.76 years (range 18 to 70, SD 14.1
with depression. They found that SI was significantly years) and mean BMI 24.24 kg/m2 (range 19-
associated with an elevated inflammatory index, and this 33, SD 4.01 kg/m2).
was independent of both the severity of depression and
3. Control group II: 30 healthy controls subjects
whether the patients had recently attempted suicide7.
(13 men and 17 women) without any
Alteration in lipid levels has been found not only symptoms or signs of MD based on a clinical
in medicated, chronic patients, but also in drug-naive examination were randomly selected from the
patients with first-episode of psychiatric disorders, as municipal population. Mean age of the healthy
demonstrated in a recent meta-analysis comprising 19 controls was 31.1 years (range 20 to 67, SD
studies, which revealed lower levels of TC in patients 15.4 years) and mean BMI 24.1 kg/m2
with MD compared to healthy controls 9. Although some (range 16-35, SD
human studies have investigated a possible connection 4.65 kg/m2).
between low TC and suicidal behavior 10-12, others The exclusion criteria were as follows: (1)
studies have shown no relationship between suicide and Patients with self-injurious behaviors were
lipid parameters 13, 14. Because of the conflicting results determined to have no suicidal intention or
of the CRP and lipid profile on suicide, we want to focus ideation, any past or present major medical or
on these subjects. The aim of current study were (1) to neurological illness, and a current axis I
verify whether an alteration in the CRP, and lipid profile comorbidity and/ or comorbid personality
increase the risk of suicide in patients with MD or not, diagnosis. (2) Patients with chronic diseases
and (2) to exam the correlation between these variables such as hepatic disorders, diabetes mellitus,
in patients with MD. To our best knowledge, this is the hypertension, cardiovascular disease, common
first study that has been achieved in Iraq. cold, influenza, or any other inflammation.
Finally (3) Patients who receiving anti-
Subjects and Method inflammatory, statin and/or immunosuppressive
therapy.
A. Subjects: After the approval of protocol by the
Ethical Review Board for human studies, faculty All study participants went through a structured
of nursing/university of kufa/Iraq (No. 4- interview by a specialist in psychiatry and were
04/01/2017), a case-control study was conducted in diagnosed according to the Diagnostic and
emergency departments and Psychiatric Clinic at Statistical Manual of Mental Disorders (DSM-
two large teaching hospitals (Al-Sader hospital IV) and evaluated using Hamilton Depression
and Al- Hakeem hospital) in Al-Najaf province, Rating Scale (HDRS) and the Beck’s Suicidal
Iraq, from October 2017 to July 2018. All patients Ideation Scale (BSSI). The scale had
gave their written informed consent before acceptable reliability in our sample
enrollment. (Cronbach’s α = 0.93). Five ml blood sample
was obtained between
1. MD patients with Suicidal Attempter (SA):
7.30 and 8.00 by venous puncture from each
22 patients (16 men and 6 women) were
controls after an overnight fasting period, while
enrolled on admission to emergency
for SA, five ml blood sample was collected at
departments of two large teaching hospital
the time of admission to the emergency room
(Al-Sader hospital and Al-Hakeem hospital)
after the failed attempt. The blood was set in
after a failed suicide attempt. Mean age of
an EDTA tube, and then plasma was separated
the patients was 36.91 years (range 18 to 48;
by centrifugation at (3000 rpm) for 15 minutes.
standard deviation (SD)
Human CRP were assayed using the DuoSet
10.3 years) and mean body mass index (BMI)
ELISA Development System (R&D Systems,
25.98 kg/m2 (range 16-36, SD 6.34 kg/m2).
Minneapolis, MN, USA). Total Cholesterol and
2. Control group I (MD patients with Non- Triglycerides were determined by enzymatic
Suicidal Attempter (NSA)): 38 patients (24
571 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 571
CHOD-PAP and GPO-PAP calorimetric
method.
B. Statistical Analyses: Numerical data were and Standard deviations of CRP and lipid parameters are
presented as mean ± standard deviation (SD). summarized in (Table 1). The comparative analysis of
Categorical variables were presented as the CRP and lipid profile among three studied groups
proportions. Differences among SA, NSA, and showed significant differences in the CRP, TC, and TG
control group (healthy subjects) were estimated (all p<0.05).
using ANOVA (Kruskall Wallis test for skewed
data) for numerical variables with an additional Post-hoc analysis for CRP, showed that SA had
Bonferroni post-hoc test. All statistical analyses significantly higher CRP production than Non-suicidal
were performed using the statistical package MD patients and normal controls (X2 =30.921, df = 2, p
SPSS version 20 (SPSS Inc., Illinois, USA). The <0.001). When examining CRP as a categorical measure
alpha-level of significance was set at p < 0.05. [high CRP (=>3) vs. normal CRP (<3)], we did not find
any significant differences in the CRP subgroups
(X2
Results
=2.003, df = 2, p=0.367).
A total of 60 patients with MD (40 men and 20
Furthermore, TG level was significantly higher in
women) and 30 healthy controls (13 men and 17
both SA and NSA (p=0.009 and p<0.001 respectively)
women) were included in the study. The patients were
compared with healthy control. No significant difference
categorized into two groups according to suicide
for TG level was observed between SA and NSA
attempts. Means
(p>0.05).

Table 1: Mean ± Standard deviation for Levels of CRP and lipids in SA, NSA and HC
SA NSA HC
Post-hoc
n=22 n=38 n=30
analysis
Mean ± SD Mean ± SD Mean ± SD Statistics p value
CRP 6.41 ± 2.76 2.71 ± 0.48 2.40 ± 0.33 X =30.921, df =2
2
<0.001 SA>NSA, HCab
TC 155.55 ± 8.65 172.02 ± 7.71 174.07 ± 8.82 F=36.733 <0.001 SA<NSA, HCc
TG 166.19 ± 36.77 175.98 ± 29.13 140.90 ± 37.35 F=9.185 <0.001 SA, NSA>HCc
n % n % n %
CRP status
Normal 12 54.5% 24 63.2% 22 73.3%
X2 =2.003, df =2 0.367
High 10 45.5% 14 36.8% 8 26.7%
Abbreviations: a=Those data were analyzed by using Table 2: Correlation among CRP, lipid profile and
the Kruskal–Wallis test; b=The Dunnett C method Clinical scores (HDRS and BSSI)
was used for post hoc comparisons; c =The Bonferroni
method was used for post hoc comparisons; CRP TC TG
SA=Suicidal attempter; NSA=Non-Suicidal attempter; SA
HC=Healthy control; TC=Total Cholesterol; TC 0.050
TG=Triglycerides; and SD=standard deviation. TG 0.143 0.258
C. Correlations among CRP, lipid profile, HDRS 0.524* 0.018 0.423
depression symptoms and suicidal severity BSSI 0.610** 0.010 0.323
in SA and NSA: As shown in (Table 2), SA * p < 0.05
had significantly positive correlations between
** p < 0.001
CRP and total HDRS scores (r=0.524, p=0.012).
Moreover, SA had significantly positive
Discussion
correlations between CRP and BSSI scores
(r=0.610; P=0.003). For non-suicidal MD patients, We measured CRP and lipid profile in plasma of
No correlations were observed among all studied healthy control subjects, non-suicide major depressive
parameters. disorder and suicide attempters with well-defined
clinical psychiatric profiles. In this study, while the organization of the 5-HT1A receptor 19. Results from
levels of CRP was significantly higher in suicide additional studies showed that the fluidity of lipids
attempters than non-suicidal MD patients and healthy considerably regulates the binding of serotonin (5-HT)
controls, the level of TC among suicide attempters were in murine brain membranes. It is therefore expected
significantly lower than those among non-suicidal that decreased levels of cholesterol would increase the
depressed patients or healthy control subjects. Other fluidity of the cellular membrane. While, at the same
studied parameters did not show any statistically time, minimal exposure of the 5- HT receptors would be
significant difference among study groups. found in the synaptic cleft 12.

Our finding was agreement with a study showed that The present findings ought to be viewed as
depressed patients with suicidal attempter had higher preparatory in light of many limiting factors: First-
serum CRP levels compared with depressed patients the small size of the sample limits causal conclusions
with non suicidal attempter and healthy controls 7. in regards to the correlation between inflammation
Although Courtet et al. recently reported increased and suicidilty. Second- MD Patients in current study
CRP levels in depressed patients with history of suicide were doctor’s facility in-patients get upper and other
attempts, they found no difference in the CRP levels of psychotropic medicines and a few members were
suicide attempters who had CRP measured within 7 days utilizing calming pharmaceuticals, all of which could
of the attempt or later 15. Vargas et al. did not find have impacted levels of our needy factors 20. Finally,
differences in CRP levels between patients with and current study can’t represent lifetime stretch introduction
without history of suicide attempts 8. However, specific or comorbid psychiatric disorders that could have added
alleles in the CRP gene are more common among to our watched example of results.
depressed patients with history of suicide attempt.
Lastly, in psychiatric populations, a CRP level of 5 mg/L Conclusions
differentiated responders and non-responders to anti-
inflammatory treatment of depressive disorders Our findings support the hypothesis that CRP, and
TG are associated with suicide attempts in patients with
(infliximab) 7.
major depressive disorder. The identification of valid
Our second finding of decreased levels of total and accessible biological markers of suicidal behaviors
cholesterols and low density lipoproteins in suicide still represents a challenge for future research.
attempters with MD compared to control depressive
Conflict of Interest: Nil
patients or healthy control subjects is consistent with a
recent study 1 as well as, coincide with the conclusions Source of Funding: Self.
of a meta-analysis published in 2015, which included a
total of 65 different studies, found overall association Ethical Clearance: After the approval of protocol
among lower TC level, and suicidality 12. However, by
the Ethical Review Board, university of kufa/Iraq
other reports did not find an association between
(No.
plasma TC, and suicidality 16.
4-04/01/2017) and before enrollment, all subjects
With respect to triglyceride levels, our results gave
showed higher levels of triglycerides in suicide their written informed consent.
attempters and non suicidal attempters with MD. Our
finding coincides with previous studies, which found a References
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DOI Number: 10.5958/0976-5506.2019.01633.4

Considered Absorption Spectra for Identification of Blood

Constituents

Hassan Abdullah Mahdi1, A. A. Al-Rubaiee1, Muhanad M. Azzawi2

Department of Physics, College of Science, Mustansiriyah University, Baghdad, Iraq;
1

2
Laser and Electro-optic Research Center, Ministry of Science and Technology, Baghad,
Iraq

ABSTRACT
This research is the first which it contains the considered absorption spectra for identification of blood
constituents and biological liquids. The spectrophotometer is used for measuring the absorption spectra of
blood constituents and determining the peaks of its absorption. The agreement of the peaks and
wavelengths is demonstrated for more clinical analysis. The blood or plasma and some biological liquids
are used for detection of clinical constituents from unknown samples. This way is very useful for diagnosis
and for clinical analysis. It was prepared a large number of test samples for group persons (female & mate)
in different ages. It is measured the results of more analysis that considers absorption spectra for
identification of blood constituents.

Keywords: Absorption spectra, blood constituents, clinical analysis, peak absorption, biological liquids.
Introduction Spectrophotometer Description: The optical diagram
of the spectrophotometer that used for measuring the
The present work is the first that considers the
spectra absorption for test samples is shown in the
absorption spectra for identification of blood
Figure 18. The spectrophotometer contains tow lamps,
constituents. There are some significant advantages as
one of them is tungsten lamp with wavelength range
following1, 2:
(322.5-800) nm; and the other is deuterium lamp with
1. It refers to laser possibility in clinical analysis wavelength range (190-322.5) nm.
which locating within the wavelength of laser
which it used and compared with the peak
absorption which it is corresponds to the
magnitude for the wavelength of that laser source.
2. High accuracy in the test samples method and in
the added chemical materials, that gave a good
evidence for errors detection3, 4.
3. When adding chemical materials with incorrect
ratios, that it refers to wavelength or absorption
errors5-7.

The present work is significant because it is

possible to determine known chemical constituents from
unknown samples, therefore it is helpful in diagnosis the
disease cases.

Corresponding Author:
Ahmed Azeez Al-Rubaiee
Department of Physics, College of Science Figure 1: Optical diagram for spectrophotometer8
Mustansiriyah University, Baghdad, Iraq
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 575

Absorbance Spectroscopy Measurement: The Conted…

spectrophotometer was used in this research to measure
the absorbance spectroscopy for blood constituents and Cholesterol, Uric
2. 500, 520 500
some biological fluids and determine the absorption Acid
peaks9. A good agreement had been observed between 3. Sugar, Uric Acid 500, 520 480
these values and wavelength of used Argon laser (488- Creatinine, Fluid 492, 540,
514.5) nm. In the approach of the present work, the 4. 600
Protin, Urea 580
absorption spectra helped in detection of known
constituents from unknown solutions which help to The deviation of the wavelength from its real value
diagnosis the clinical feature of the results that had a is given by two reasons:
significant value. To calculate the concentration or
activity for those clinical analyses, one can prepare the 1. In case of (λ1 <λ0 < λ2 ), it is called mass shift,
test samples for many times and different cases for group which follows the molecular weight.
of people (male and female) in different ages and putting
2. In case of (λ0 >λ2 and λ0 > λ1 ), this is leads to new
the samples in the spectrophotometer and measure the
formation.
absorbance.

Results and Discussion

The present work can be summarized through
mixing two or more of known samples with equal
amounts for each type after preparing and putting in
the spectrophotometer. Through measuring absorption
spectra, it was noted that the peak absorption of some
types are overlapped because approaching the values of
its wavelengths. Also these wavelengths of samples gave
an agreement with the deviation in some values such as
wavelengths and absorption. In Table 1 was shown the
known chemical analysis form unknown samples with
one-peak as demonstrated for each type in the figures.
Through figures (2, 3), a good agreement was
demonstrated between the absorption peaks and
wavelengths. This is positive indicator for measurements
of each clinical analysis for appropriate wavelength.
This scientific and experimental fact leads to
diagnosis the diseases cases by the specialists after
noting the absorption peak with its wavelength which
refers to that type of analysis.
& is this lie in normal or abnormal values for
concentration or activity.
From Table 1 and Figures (2, 3), one can distinguish
known clinical analysis from unknown samples with
one-peak because of the overlapping in its wavelengths.

Table 1: Clinical composition from overlap samples

(1. Peak)
The Resulting wavelength
Overlapped wavelengths
Species Overlap in Situ (nm)
No. (nm)

Sugar, Fluid
1. 500, 540 520
protein
576 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Figure 2: Determination of clinical composition

from overlapped samples a: (Sugar, Fluid protein);
b: (Cholesterol, Uric Acid)

Figure 3: Determination of clinical composition

from overlapped samples a: (Sugar, Uric Acid); b:
(Creatinine, Fluid Protin, Urea)

Conclusions

The present work can be concluded as follows:

1. Inventing a new method in clinical analysis by
considering absorption spectra for identification
of blood constituents.
2. It is considered that this method is a basis for
constructing a specialized laboratory for clinical
blood analysis and some biological liquids.
3. Determining known clinical constituents from
unknown samples, which it help to diagnosis the
disease cases with high accuracy.
4. The absorption spectra is a conclusive evidence
for the correct or incorrect results of analysis, also
it is possible to determine the errors when happen
by using this method.
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 577

5. By using this method, it is not needed to add 3. Tietz N. M. Fundamentals of clinical

chemical materials into samples according to the chemistry,
usual ways. Therefore, this way is an economy 1976.
way because there is no need to add more of
4. Gary M. Hieftje, Lasers in chemical analysis,
chemical materials.
1981.
Financial Disclosure: There is no financial disclosure. 5. Bradlev Moore C. Chemical and Biological
applications of lasers, 1977.
Conflict of Interest: None to declare.
6. Breck Hitz C. Understanding laser technology,
Ethical Clearance: All experimental protocols were 1990.
approved under the Department of Physics/College of
Science/Mustansiriyah University, Baghdad, Iraq and 7. Glenn F. Knoll. Radiation detection and
all experiments were carried out in accordance with measurement, Joun Wiley and Sons, 1979.
approved guidelines. 8. Beckman A. O., Gallaway W. S., Kaye W.,
Ulrich W. F. History of spectrophotometry at
REFERENCES Beckman Instruments, Inc, Analytical Chemistry.
1977; 49 (3).
1. Ehlotzky F. Fundamentals of laser interactions,
1985. 9. Wormell P., Rodger A. Absorbance Spectroscopy:
Overview. In: Roberts G.C.K. (eds) Encyclopedia
2. Wilson J. and Hawkes J. F. B. Optoelectronics an
of Biophysics. Springer, Berlin, Heidelberg, 2013.
introduction, 1987.
DOI Number: 10.5958/0976-5506.2019.01634.6

Evaluation of the Concentration of Some Heavy Elements of

Selected Soils from Shatrah City

Ibtihaj Ahmed kadhim1, Mohammed Abdulabbas Hasan2

1
Biology Science Department, College of Education for Women, University of The Qar, Iraq;
2
Department of Pathology, Faculty of Veterinary Medicine, University of Basra, Iraq

ABSTRACT
The study aimed to measure the concentration of five heavy elements in the soil of Shattrah City. Attempt
to detect the number of pollution levels of heavy metal and make comparisons between this level and
international standard determinants.Using Atomic Absorption Spectrophotometer device (Flam Atomic
absorption (FAA)) We were selected (7) different stations in the city, including (old crowded residential,
industrial, modern crowded residential, Industrial, area exposers bombed in 2003, and areas closed to the
busy streets to vehicles) samples were collected during the month of June and July of 2016 -2015, Values
were arranged[(171.6857 ppm), (12.27 ppm), (66.4142 ppm), (21.5 ppm), (20.928 ppm)] respectively, the
present results indicate that there were high ratio of lead, cadmium and zinc in all study areas and this other
evidence of soil contamination.

Keywords: The Soil, The heavy metals and The Shattrah city.
Introduction problems caused by the environment closely related to
their positions in the periodic table. Their gravity is due
Heavy metals are among the most dangerous
to the fact that they are transitional elements and have
environmental pollutants due to their high toxicity
the ability to form stable complexes with a large group
and their easy accumulation in the tissues of different
of organic and inorganic compounds in living organisms
organisms. The continuous increase in these minerals [7]
.Soil is one of the major repositories of human waste
is due to the effluents from sewage treatment plants,
and the processes that biochemical can be mobilized to
power plants, processing, mining and agriculture [1].
contaminate water supplies and the impact on food
Heavy elements include a wide range of elements,
chains [3]. Heavy metals are released from their sources
including what is necessary for the vital activities of
far from their emission point with the help of the
living organisms in fixed proportions, including what
atmospheric (wind). PH is also an important measure in
is unnecessary and which are substances contaminated
the soil system as it directly or indirectly affects
and high toxicity of living organisms [2]. Heavy metals
absorption, sedimentation, decomposition, complex
are known to have high densities of more than 5 gm/
formation, oxidation and reduction reactions and is
cm and are very low in living systems and have high
important in determining the behavior of these
stability. These elements can be classified into low toxic
elements In the soil [7]. As well as the importance of
elements such as manganese with moderate toxicity such
organic matter in the soil, which consists of living
as chromium, copper, nickel and severe toxicity such
organisms and biochemical (amino acids, proteins,
as uranium and lead And cadmium. [3,4,5]. The toxicity
carbohydrates and organic acids) and affect these
of these mineral elements is related to their physical-
materials on soil construction and water retention [3].
chemical composition. Minerals can be found in nature
on multiple images, such as the iconic image associated Study Area: The Shattrah is located on a branch of the
with water or in multiple complexes with organic and Gharraf River, which descends from the Tigris River in
inorganic compounds. These compounds are based the central Euphrates region of southern Iraq about 350
on electrostatic, [6]. The chemical properties of metals Km south of the capital Baghdad at latitude (31,4175)
as well as their degree of toxicity are related to the the latitude (46,1777),Its population is (254,000) people
579 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 579

according to the statistics of 2014. The following 4. Collect the sample by adding 15 mL of
administratively and geographically in the province of hydrochloric acid with 5 mL of concentrated nitric
Thi-Qar is located midway between Baghdad and the acid HNO3
southern provinces and the Arabian Gulf. This is what
5. Put in a sand bath for 60-45 minutes
enabled it to occupy a vital geographical location for its
control of the transportation and road transport between 6. Refrigerate the baker to laboratory heat and add 5
Baghdad and the Arabian Gulf on the one hand and ml of hydrochloric acid and heat in a sand bath to
between Baghdad and the rest of the southern city on the dry, for 5-10 minutes.
other. The district of Shattrah is the second largest
7. Cool the cup and add 5 ml of hydrochloric
district in Iraq, with an area of (2,384 Km2), acid
administratively bordered by Maysan Province and the and 50 ml of hot distilled water
west by Al-Nasr. On the north side is the district of Rifai
the south is Nasiriyah. The judiciary includes three 8. Heat the mixture to boiling point for 2-3 minutes
administrative areas Dawa [8], as illustrated in Figure (1). 9. filtration with filter paper. 42, located in a
bottle
size of 100 ml
10. Wash the insoluble precipitation with distilled
water and add the washing water to a site and
complete the volume to 100 ml and then send
it for analysis by Flam Atomic Absorption
Spectrometer.

Results and Discussion

The results of the study showed a high concentration

of the lead element in the soil samples (7 stations)
from different areas in Shatrah compared to the Iraqi
Figure 1: Thi-Qar Governorate Map shows an aerial determinants of 150 ppm , as in Table (1). Where the
[11]

view of shattrah Cities[9] industrial area recorded the highest concentration of

the lead element because of the large number of cars
Materials and Mode of Pperation: Various samples of and blacksmith shops and the spread of ice factories.
the soil for each station for (7) different stations
The bombing during the 1991 and 2003 wars also
[Industrial neighborhood, Imam Sadiq neighborhood,
contributed to the explosion of bombs and missiles,[12]
hospital district, Technical Institute neighborhood, [13]
. Resulting from the combustion of fuel containing
Baghdad district, Mashtal, Imam Hussein neighborhood
tetraethyl, which uses lead or the fourth generation to
(p) During the months of June and July of 2016-2015,
reduce the engine helps to increase the lead pollution
industrial, residential and commercial areas, the samples
in the environment of the combustion of fuel used
were stored in nylon bags after modeling [10] was used to
in local power generators deployed in residential
calculate the concentrations of heavy elements in selected
neighborhoods is a source only as well as lack of health
soil samples. The following are the basic stages of
and environmental services, Resulting in degradation
processing samples and preparing them for final analyzes:
and increased heavy concentrations [Pb, Cd, Ni, Cu,
1. Grinding the soil sample using a ceramic Cr] insisted in soil [14] When comparing the results of
mortar
the current study with local studies according to Table
after drying in a 100 ° C oven for two hours.
(2), we noticed that lead concentrations recorded higher
2. Screening of samples using a sieve (0.63 μm) results than the Iraqi determinants [15] and higher than
3. Place (1 g) of the dried sample in a 250 ml clean recorded [16] in the soil of Kufa and recorded
[17]
From
beaker using a delicate balance the record [18]
in the soil of Baghdad - Nahrawan and
recorded [19]
in the soil of Basra and recorded [20]
in
the
soil of architecture and recorded [21] in the soil of Kut The zinc content of the soil is highly heterogeneous and
and higher than recorded [22] in the soil of Nasiriyah And due to the resulting rocks in terms of the concentration
recorded by [12] in the soil of Baghdad and recorded [23] of nickel and copper, we note that the current study
in the soil of the city of ancient Ur We also noted the rates recorded fewer results than the Iraqi determinants
increase in concentrations of cadmium compared to the [15]
Of the recorded [16] in the soil of Kufa and recorded
Iraqi determinants of 5ppm per million [11]. In his study, [17]
.And recorded by [20] in the soil of architecture and
[24]
pointed to the role of temperature rise and wind recorded [21] in the soil of Kut and higher than recorded
direction, and the effect of pollutants on it, And [25] That [22]
in the soil of Nasiriyah and recorded [12] in the soil
fuel combustion products used in brick factories are of Baghdad and recorded [23] in the soil of the city of
working to increase trace elements in the atmosphere Ur archaeological and slightly higher than recorded [19]
and then deposition on the soil surface. According to in the soil of Basra. The concentration of this element
[26],
one of the reasons for increased concentration of in the industrial area is confirmed by the fact that the
cadmium in soil is the burning of plastic materials. Note pollution is the result of the burning of fuel used in
that the cadmium concentration record highest rate local electric power generators, which are widespread
[15.3 ppm] in the industrial zone, which ranks first. in the residential areas and constitute a major source of
This is due to fuel combustion products in pollution of the surrounding heavy elements, as well as
transportation and a number of kashi, block, ceramics the lack of health and environmental services such as
and fuel combustion products in civil power generators the discharge of wastewater and the accumulation of
and cadmium concentration in the Baghdad area waste and household waste. Which are complex and
[14ppm]. As well as the exposure of the region to a US heterogeneous and thrown into the soil, leading to their
missile strike in 2003, poor sanitation services and degradation and increased concentration of heavy metals
household waste Rh on the surface of the soil. When [Pb, Cd, Ni, Cu, Cr] in the soil [14]. The region is located
comparing the results of the current study with local near the filling station of Benzin and was hit by missiles
studies, we observed that zinc concentrations were in 2003 and has been suffering from environmental and
recorded [66.4142 ppm], higher than Iraqi determinants health neglect for many years.[28] confirmed in their study
[15]
and higher than global determinants (50 ppm) [11] that the concentration of nickel and copper Is higher in
and higher than recorded in Jabbar [21] And recorded [22] the summer season than in other seasons due to the high
in the soil of Nasiriyah and recorded [23] in the soil of temperature and the effect of the effect on the behavior
the ancient city of Ur. We observe the rise of the zinc of pollutants if it works to lift pollutants to the upper
element in the same areas where the concentration of layers and thus increase the spread to long distances,
lead and cadmium increased by the fact that zinc is illustrate the forms (3) Concentrations of heavy
not available individually but is uniformly present. elements in the
In soil of the study areas.
areas with poor health and environmental services.
[27]

Table 1: Concentration of heavy metals in the study area

Table 2: Comparison of the concentrations of heavy metals in the study area with the Same in local soil and
the global average

Conclusions and allocate areas far from the city for

sanitary
This study shows the increase in lead, cadmium landfill and removal of construction waste
and zinc concentrations in the samples. Due to several
factors,mainly the quality of fuel used in cars and Conflict of Interest: None of the authors have any
local power generators, poor health and environmental conflicts of interest to declare.
services and the accumulation of household waste,
which led to deterioration and increased concentration of Source of Funding: The research was performed
heavy metals [Pb, Cd, Ni, Cu, Cr] All of which independently, there is no funding, influence over study
contributed to increasing the concentrations of pollutants design, analyses, manuscript preparation, or scientific
on the surface of the soil as well as to the incorporation publication.
of chemical fertilizers and pesticides and their role in the Ethical Clearance: The project was approved by the
pollution of agricultural land, local ethical committee (Biology Science Department,
College of Education for women/University of The- Qar.
Recommendations
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DOI Number: 10.5958/0976-5506.2019.01635.8

The Effect of Theory of Planned Behavior Models to Behavior

of Cadres as the First Aiders of Stroke Attacks

Imelda Feneranda Seravia Tambi1, Yuyun Yueniwati2, Setyoadi2

1
Student of Master of Nursing Study Program, 2Lecturer, Faculty of Medicine, Brawijaya University

ABSTRACT
Background: Identification of stroke patients as early as possible is very important, this can help improve
prehospital management and the accuracy of treatment. Public awareness can contribute to increasing the
speed of arrival at the hospital after the attack.
Research Objective: to analyze the effect of model-based on the theory of planned behavior training on
knowledge, attitudes, subjective norms, perceived behavioral control, intention and behavior of cadres as
the first aider in identifying stroke.
Method: This study uses the true experimental method pre and post test control group design. This study
included one experimental group (22 health cadres) and one control group (22 health cadres). Sampling
uses simple random sampling. Training based on the model theory of planned behavior is carried out for 5
sessions. Data collection was conducted twice, namely before training, 1 week after training and measuring
behavior 1 month after training.
Results: Training based on the model of the theory of planned behavior affects knowledge (0,000 < 0,05),
attitudes (0,006 < 0,05), perceived behavioral control (0,000 < 0,05), intention (0,007 < 0,05) and behavior
(0,000 < 0,05). Training does not affect subjective norms (0.057 > 0.05). Differences in the two groups only
occurred in the variables perceived behavioral control (0.002 < 0.05) and behavior (0.000 < 0.05).
Conclusion: Continuous training is very important in improving cadre behavior in carrying out its role,
namely the ability to identify and respond to stroke quickly. This is expected to support the success of the
prehospital care system in the community.

Keywords: stroke, first aider, theory of planned

behavior
Introduction Increasing prehospital handling can be done by
training local residents. Local programs can help nursing
Provision of rapid treatment can be achieved by staff to work with first aid workers and community
reducing patient time in making decisions, increasing health workers. Activities include increasing skills
early identification and rapid examination (1). Lack of to local residents to recognize disease and doing first
understanding of the introduction of stroke symptoms aid(5). The right target in implementing community-
results in delayed treatment (2). The evidence shows that based education is cadres. Cadres can help professional
public awareness regarding stroke is less optimal. health workers in areas that have limited resources (6).
Cadres have a role in carrying out first aid measures for
According to data from the Malang City Health patients. The obstacles faced by cadres are that the level
Office in 2017, 379 stroke patients were found in the of education that is still lacking and inadequate(7).
Janti Community Health Center work area. Patients
with risky diseases, including 1,895 diabetes mellitus The training provided should not only focus on
and 2,426 people with hypertension. These data indicate increasing knowledge, but increasing the behavior of
cadres as the first aider. One effort to improve health
that handling prehospital is of particular concern to the
education is to utilize the use of the theory of planned
community. The presence of a community can increase
behavior (TBP) (8). This theory can design and
knowledge about stroke signs and risk factors(4).
implement educational interventions to change
behavior. Increased
585 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 585

preparedness for stroke and self-efficacy which are Results and Discussion
steps needed to increase the speed of treatment of acute
stroke(9). Educational intervention based on the TBP has
Table 1: Characteristic Distribution of Respondent
a significant influence on subjective norms and
behavioral intentions (10). Based on the evidence of the No. Characteristic Total (%)
effectiveness of the theory, the research applied training 1. Gender
based on the theory of planned behavior on cadres as the
Female 44 100
first aider in dealing with stroke.
2. Age
25-35 5 11
Method
36-45 15 34
This study uses the true experimental method 46-55 24 55
pre and posttest control group design. There were 3. Education
experimental groups and control groups, each consisting Junior high school 20 45
of 22 health cadres. Sampling uses simple random Senior high school 19 43
sampling. Data collection was conducted twice, namely
University 5 11
before training, 1 week after training and measuring
4. Duration of being cadre (year)
behavior 1 month after training. The questionnaire used
was designed based on the theory of planned behavior -5 24 55
with a Likert scale of 1 to 7 (not agreeing to strongly >5-10 2 5
agree). Data were analyzed using parametric and non- >10 18 41
parametric tests. The training based on the model of the 5. Type of Work
TBP was carried out for 5 sessions with a duration None 26 59
of Private 5 11
10-60 minutes. This research has passed ethical conduct entrepreneur 13 30
tests at the Ethics Committee of the Faculty of
Medicine, Brawijaya University no 345/EC/KEPK-
S2/12/2018.

Table 2: Effects of Theory of Planned Behavior Based Training on Experimental Groups

Experiment Control Uji Wilcoxon
Variable Median Min-Max Median Min-Max p value
Knowledge 60 33-80 87 53-100 0.000
Attitude 49 -30-75 62 21-75 0,006
Subjective Norms 36,5 -9-91 65 5-81 0,057
PBC 10,7 -18-27 36 -20-64 0,000
Intensity 12 2-13 13 10-14 0,007
Behavior 10 0-50 40 10-100 0,000

Table 3: Effect of Lecture Method on Knowledge, Attitude and Subjective Norm

Before Training After Training
Variable Mean SD Mean SD p Test
Knowledge 56,59 15,46 83,59 13,48 0,000 Paired t-test
Attitude 46.36 21.92 47.50 16.60 0.862 Paired t-test
Subjective Norms 60.00 24.76 58.55 26.51 0.783 Paired t-test
Table 4: Effect of Lecture Method on PBC, Intention and Behavior
Before Training After Training
Variable Median Min-Max Median Min-Max p value Test
PBC 7.5 -33-48 3.5 -30-84 0.795 Wilcoxon
Intention 12.5 6-14 12 10-14 0.570 Wilcoxon
Behavior 10 0-40 10 0-70 0.066 Wilcoxon
Table 5: Comparison of Analysis Results on Knowledge and Subjective Norm
Experiment Control
Variable p value Test
Mean SD Mean SD
Knowledge 21,27 15.30 27 17,9 0.261 Independent sample test
Subjective Norm 16,95 38,41 -1,45 24 0.066 Independent sample test.

Table 6: Comparison of Analysis Results Attitute, PBC, Intention and behavior

Experiment Control
Variables P Test
Median Min-Max Median Min-Max
Attitude 9,5 -27-93 -6 -48-76 0.067 Mann-Whitney
PBC 34 22 -4,5 -68-105 0.002 Mann-Whitney
Intention 1 -2-8 0 -4-8 0.087 Mann-Whitney
Behavior 35 0-70 0 -20-30 0.000 Mann-Whitney
*Perceived Behavioral Control= PBC
Table 1 shows that all respondents were female This is in accordance with the statement that,
(100%). The highest age in this study was in the range of knowledge is the result of the process of knowing and
46-55 years (54%). The most characteristic of education happening after someone feels a certain object. This
is ]junior high school graduates (46%). All respondents happens through human imagination, namely the senses
have never attended training or education related to the of sight, hearing, smell, taste and touch (13). Knowledge
concept of stroke and first aid in stroke. or cognitive is domain which is very important in
shaping actual behavior.
The results showed that before the training-based
Understanding signs, symptoms and complications
model of the theory of planned behavior (TBP) cadres
is a part that supports faster and better identification of
had less knowledge of 60.59 ± 23.05. Inaccurate
strokes (14). This can lead to an increase in attitude and
knowledge is found in questions regarding stroke risk
if it is associated with health behaviors it will result in
factors, including smoking habits, old age and obesity, a better improvement in the patient’s final condition.
stroke signs and symptoms and actions to be taken Knowledge of risk factors and prevention strategies
when meeting patients with stroke. Lack of knowledge will be very helpful in reducing morbidity and mortality
related to stroke risk factors and stroke symptoms due to stroke. Interventions to educate the public about
can be influenced by education level and age(11). The the correct response to symptoms of stroke have a
respondents’ knowledge of stroke risk factors that are high success in helping the community make the right
very low can be related to the status of education as a response when finding a acute stroke(15) This finding
related factor (12). shows that first aid education must be disseminated in
every segment of society.
Data shows that there is an increase in cadre
knowledge after training (p = 0,000). There were no Model-based training TBP has an effect on cadres’
attitudes as the first aider in stroke (p = 0.006). There
differences in the two groups (p = 0.261). This shows
were no differences in the two groups (p = 0.067). This
that both training methods can increase knowledge.
shows that the two methods used do not have an effect
90.9% of cadres knew of stroke risk factors, 81.8% of
on improving attitudes. The activity in the experimental
cadres knew the signs and symptoms of stroke and group aims to ensure the positive outcome as the first
100% of cadres knew the act of contacting an aider. The series of activities was carried out by giving
ambulance. Efforts to increase knowledge in the TBP the topic a discussion to the cadres regarding the impact
training model are carried out by brainstorming and of the delay in identifying strokes, how strokes could
group discussion in solving the given cases and change the lives of people and family members. This
demonstrating stroke assessment steps to draw session also provides an opportunity for cadres to share
conclusions from the results of the assessment. experiences in dealing with patients with stroke.
This activity is based on the findings of Pooreh and factors, such as previous experience(21). In this study
Hosseini, that attitudes toward the subject come from efforts were made to improve the perceived behavioral
one’s beliefs about the subject. That is, the beneficial control through brainstorming. Provide opportunities
consequences of a behavior will increase the for cadres to identify constraints within the group and
individual’s attitude towards that behavior(16). Attitudes present the results of the discussion, explain constraints
towards stroke are influenced by knowledge and and strengths in carrying out roles as cadres and make
supported by actions taken to prevent and treat stroke. collective agreements through the formulation of
Accurate knowledge of stroke risk factors and stroke strategies to overcome these obstacles. Activities that
warnings, appropriate stroke prevention measures or can develop perceived behavioral control are identifying
immediate actions needed to treat stroke patients (17). constraints, making collective agreements to make
strategies in dealing with these obstacles and providing
Model-based training TBP has no effect on
motivation(18).
subjective norms (p = 0.057). The two groups did not
show differences (p = 0.066), so the two methods in this Training based on the TBP has an influence on
study did not increase subjective norms. The results of intention (p = 0.007). There were no differences between
this study are in line with the findings of Skolarus et al, the two groups (p = 0.087). Increased intention in the
that training related to reducing the delay in stroke care experimental group was influenced by high knowledge,
has no effect on subjective norms (9) attitudes, PBC after being given training based on the
TBP. Stability of intention can occur if there is a lag
There are low and negative perceptions on social between the measurement of intention and observation
support that is felt in their role as the first aider. To of behavior. The difference between the initial and
increase subjective norms were carried out by forming final intentions will occur. After measuring intention,
social media groups by utilizing social media to provide things will be found that can change one’s intentions.
motivation. The formation of subjective norms in their The greater the intention will change if the longer the
application in the field of education or training is time interval(22). Karimy et al. expressing TBP is useful
through the practice of forming groups and providing for changing attitudes, subjective norms, perceived
motivation(18). The lack of support and motivation of behavioral control and behavioral intentions for healthy
cadres was disclosed during the assignment evaluation. lifestyles among patients with myocardial infarction(23).
The results of this study pay special attention to the
The theory of planned behavior is one of the key
quality and motivation of health cadres in carrying out
theories in the application of first aid. After training
their roles. most cadres assessed four to five patients from ten
The feeling and support of a community is an patients. The assessment not only included blood
pressure, pulse, breathing, but all respondents assessed
important influence on the satisfaction of a first aider in
their ability to make conclusions and recommend
carrying out his role. Perceptions about the belief in their
further treatment for patients. Short stroke education
performance abilities, feelings of belonging and being
interventions have the potential to positively influence
bound to a place can be beneficial to the first aider (19).
stroke recognition and behavioral intention. This
The lack of recognition and appreciation for achieving
behavior contributes to the delay in the treatment of
health cadres can reduce their motivation. Social prehospital strokes(24). Health care providers should
acceptance, enthusiasm for serving the community and emphasize the importance of contacting help if they
achieving something useful for the community are the find signs and symptoms of stroke rather than seeking
factors that motivate health cadres to continue to play a care at a service provider.
role in health services(20).

The effect of model-based training on TBP occurs in Conclussion

increasing the PBC (p = 0,000). There were differences
Training of cadres as the first aider based on the
in the two groups (p = 0.002). These results indicate theory of planned behavior model can significantly
that training based on TBP model is more effective in influence knowledge, attitudes, perceived behavioral
improving PBC. Perceived behavioral control refers to control, intention and behavior. The results of the study
the existence of necessary resources and opportunities show the importance of ongoing training to improve
for certain behaviors and is influenced by a number cadre behavior in carrying out their roles.
of
Conflict of Interest: None Female Students ’ Obesity-Related Behaviors.
2015;12(4).
Source of Funding: This study was fully funded by
STIKES DIRGAHAYU SAMARINDA 11. Aldebasi KA, Alamri NM, Alqahtani AM.
Knowledge, Attitude and Practicetowards Stroke
Risk Factors and Warning Symptoms in Saudi
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H-AM. Impact of Educational Intervention Based
DOI Number: 10.5958/0976-5506.2019.01636.X

Factors Associated with Women’s Treatment for Urinary

Incontinence in Hasan Sadikin Hospital

Indra Gazali Syamsudin1, Karina Shasri Anastasya2, Benny Hasan Purwara1, Edwin Armawan1, Jusuf
Sulaeman Effendi1, Budi Handono1, Hadi Susiarno1
1
Department of Obstetrics and Gynecology Faculty of Medicine Padjadjaran University, Hospital Dr.
Hasan Sadikin Bandung; 2Department of Nutrition, Medical Faculty, Padjadjaran University

ABSTRACT
Urinary incontinence is a highly prevalent and burdensome condition among women. However, fewer than
half of women with symptoms talk to a physician about incontinence. The factors, including knowledge,
culture, education, and income, the most dominant factor influence and the reason patient of urinary
incontinence not to go to the hospital. The method used in this research is mixed methods with cross-
sectional research design. The sample amounted to 70 patients suffering from urinary incontinence. The
patients interviewed were 10 patients/informants.The quantitative research with the Kolmogorov test is
known that on the variable of educational and income factors, with P >0,05. The knowledge and cultural
factors result with P <0,05. There is correlation between knowledge and eastern culture with urinary
incontinence patient not treatment at polyclinic RS Hasan Sadikin Bandung, the most dominant factor
influencing is the culture factor, as well as the reasons patients with urinary incontinence do not go to the
hospital, is due to not knowing that urinary incontinence is a disease and a shame.

Keywords: Urinary Incontinence, Knowledge Factor, Cultural Factor, Educational Factor, Income
Factor.
Introduction The factor that causes an IU sufferer not to seek
treatment or medical help is the lack of wrong
Urinary incontinence (IU) includes pelvic floor
knowledge and opinions about IU, this is the biggest
dysfunction, namely pelvic nerve denervation due
obstacle to treatment-seeking behavior.7-12
to labor or lower back trauma.1 According to The
International Continence Society (ICS), complaints of The research conducted by Basu et al. Stated that
inability to hold urine out involuntarily (Complain of several things that make women in the UK consider the
involuntary loss of urine).1,2.3 problem of IU to be less important than other health
problems, do not want to see a doctor with the same
The prevalence of IU in Indonesia is known to
complaints, busy work, and shame to consult with
be
doctor.8
5.8%.4 For IU patients, the financial burden that must be
borne is not cheap and tends to be expensive from year to According to the United Nations World Population
year.5 In addition to financial problems, other problems Prospect: The 2010 Revision Population Database, the
including the patient’s opinion about the severity of the life expectancy of women in the world and Indonesia
disease, shame to consult regarding incontinence, and continues to increase.9 The lack of understanding and
trust that incontinence is a normal part of the aging understanding of IU is assumed because they assume that
process.6 this condition is normal from increasing age and can heal
on its own. This is a false assumption because IU can be
Corresponding Author: prevented or treated. Delaying treatment even with
Indra Gazali Syamsudin, mild
Department of Obstetrics and Gynecology symptoms can lead to a decreased quality of life.10
Faculty of Medicine Padjadjaran University
Hospital Dr. Hasan Sadikin Bandung Through in-depth questionnaires and interviews, an
Email: [email protected] analysis of the factors that affect an IU sufferer is not
done medically.
591 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 591

Method Conted…

This study uses mixed methods (mixed methods). No. Cultural Factors
The study was observational analytic and unpaired 1. Very Low 3(4.3%)
categorical comparative analysis, with cross-sectional 2. Low 10(14.3%)
research design. The study was conducted in the 3. Medium 27(38.6%)
Gynecology Obstetrics section with a quantitative 4. High 28(40.0%)
method (questionnaire) to determine the factors that
5. Very High 2(2.9%)
influence an IU patient not seeking treatment. The study
No. Educational Factors
population was adult women (18-49 years) who came to
the RSHS polyclinic and suffered from IU since May 1. Basic Education 0(0.0%)
2017 as many as 70 people suffering from IU from 2. Middle Education 39(55.7%)
109 people who filled out the questionnaire. Data were 3. High Education 31(44.3%)
analyzed by Chi-square test or by alternative Exact No. Income Factors
Fisher test and Kolmogorov Smirnov test and binary 1. Under the Minimum wage 54(77.1%)
logistic regression p-value <0.05 was considered 2. Above the Minimum wage 16(22.9%)
statistical significance. The data obtained is recorded in No. Willingness to treat patients
the form then processed using SPSS version 24.0 for 1. Still want to seek treatment 15(21.4%)
Window.11
Do not want to seek
2. 55(78.6%)
treatment
Result
Description: For categorical data, it is presented by
The results of the descriptive study on the test number or frequency and proportion while numerical data
showed in table 1 is presented with mean, median, standard deviation and
range

Table 1: Overview of Knowledge Factors, Cultural Table 1 describes the patient’s In the table above
shows that the level of knowledge of patients suffering
Factors, Educational Factors, Factors Income and
from the largest IU is in the low category of 70%. In
willingness of patients to seek treatment in a group the cultural variable namely eastern culture that is still
of patients suffering from IU inherent in Indonesian society, it is seen that most
patients suffering from IU have a high eastern culture of
Variable N = 70
40%.
No. Knowledge Factors
1. Very Low 0(0.0%) For education variables, respondents obtained by
researchers tended to be the same between patients
2. Low 49(70.0%) with IU and patients without IU. In the respondent’s
3. Medium 7(10.0%) monthly income variable, the highest income is below
4. High 14(20.0%) the minimum wage of 77.1%. The patients who suffer
5. Very High 0(0.0%) from the biggest IU are patients who do not want to seek
treatment, amounting to 78.6%, while the remaining
21.4% still want to seek treatment.
Table 2 : Influence of Knowledge, Culture, Education, and Income Factors with Patients who still want
treatment and patients who do not want treatment in patients who suffer from IU
The group suffers from IU
Variable Take medication Do not take madication Value P
N = 15 N = 55
No. Knowledge Factors
1. Very Low 0(0.0%) 0(0.0%)
2. Low 3(20.0%) 46(83.6%)
3. Medium 1(6.7%) 6(10.9%) <0.001**
4. High 11(73.3%) 3(5.5%)
5. Very High 0(0.0%) 0(0.0%)
Conted…
No. Cultural Factors
1. Very Low 3(20.0%) 0(0.0%)
2. Low 9(60.0%) 1(1.8%)
3. Medium 2(13.3%) 25(45.5%) <0.001**
4. High 1(6.7%) 27(49.1%)
5. Very High 0(0.0%) 2(3.6%)
No. Educational Factors
1. Basic Education 0(0.0%) 0(0.0%)
2. Middle Education 8(53.3%) 31(56.4%) 0.834
3. High Education 7(46.7%) 24(43.6%)
No. Income Factors
1. Under the minimum wage 11(73.3%) 43(78.2%)
0.692
2. Above the minimum wage 4(26.7%) 12(21.8%)
Description: For categorical data, the value of p For the education variable, for IU patients who still
is calculated based on the Chi-Square test with an want to have a lot of treatment are 53.3% of secondary
alternative Kolmogorov Smirnov and Exact Fisher test education, then 46.7% of higher education, Whereas the
if the terms of Chi-Square are not met. Sign * shows majority of patients who do not want to seek treatment
statistical significance. also have a secondary education background, which is
56.4%, followed by a higher education background of
Table 2 explains the comparison between 43.6%.
knowledge, culture, education, and income factors in the
group of patients who still want treatment and patients In the respondent’s monthly income variable, the
who do not want treatment in patients with IU. In the highest percentage of income is below the minimum
table above shows that the level of knowledge of wage, which is 73.3% and the remaining only 26.7%
patients suffering from IU who still want the highest earns above the minimum wage while the largest
treatment is in the high category that is equal to 73.3% respondents are those who do not seek treatment.
while those who do not want to seek treatment, the earning above the minimum wage which is equal to
highest level of knowledge is in a low category at 78.2% while
21.8% earns below the minimum wage.
83.6%. In the cultural variable namely eastern culture
that is still inherent in Indonesian society, it can be seen There is a statistically significant percentage
that most patients suffering from IU who still seek difference between the variables of knowledge and
treatment have a low eastern culture of 60%, whereas cultural factors in the group of patients who are still
in patients who do not want treatment most respondents willing to seek treatment and patients who do not want
have a high eastern culture of 49, 1%. to seek treatment in patients suffering from urinary
inconsistencies.

Table 3: Simultaneous Influence of Knowledge and Culture Factors with Patients who still want
treatment and patients who do not want to seek treatment in patients who suffer from IU

Multivariable Analysis
Variable No.
B SE OR CI (95%) Value P
1. 0-.868 0.675 0.420 0.199
Knowledge Culture
2. 2.440 0.963 11.469 0.011**
Description: Multivariate analysis with binary logistic <0.05. The * sign indicates a value of p <0.05, meaning
regression. The independent variables included in the significant or statistically significant.
logistic regression model are the independent variables
which in the bivariate analysis have a p-value of <0.25. From the multivariable analysis in table 3, It can be
The value of significance is based on the value of concluded that multivariable only cultural factors affect
p
patients who still want treatment and patients who do also sometimes do not understand the management of
not patients with IU properly. Even though IU is a health
want treatment in patients with IU. problem that can be resolved.5,18-22

Discusion The reason for the informant who said that he was
embarrassed and taboo was because the customs of the
Subjects in the study were 109 patients with 70 Indonesian East were still considered taboo on such
people with IU. age 41-49 years which is equal to matters. So this makes an IU sufferer find it difficult to
61.43%. In the aspect of the respondent’s marital status, seek treatment, especially if IU is experienced by young
IU patients were married at 65.71%. In the last aspect of people. Hatchett’s study, et al., In 32 African-American
the education of respondents, IU sufferers had the most and Latin-American women said that they had a wrong
education with senior high school education at understanding of pelvic floor dysfunction, one of which
51.43%. In the aspect of the respondent’s work, it can was urinary incontamination and had not previously
be seen that the greatest number of patients suffering known the causes, symptoms, and treatment available
from IU is housewife work of for IU. The subjects were very enthusiastic to receive
45.71% while in the aspect of family income per month, information, especially regarding how to prevent it.13,15,20
respondents who suffer from IU are mostly patients with
income below the minimum wage of 77.1%. Educational factors, some women feel embarrassed
to discuss it, especially those who have a low
Therefore, for those with IU, the financial burden educational background.
that must be borne due to IU is considered not small and
tends to increase from year to year. Daily maintenance The reasons for not being treated because the
costs around 0.3% of Indonesia’s 2015 APBN due to the husband’s income is only enough to meet the daily
large financial burden, this has caused less than 20% of needs and needs of the child’s school. In addition, even
IU sufferers seeking help medical conditions.10 though the respondent has a BPJS (Health Insurance),
respondents are afraid of additional costs. This means
Based on the results it is known that there are many that the respondent does not have enough costs for
different reasons that cause a person to suffer symptoms treatment. However, there were also respondents who
of complaints. educational factor, and the reason that felt they needed treatment, only this would be done later
the husband’s income is not enough. In the reason of the on. Subak’s study, et al., On the impact of improving
informant who said that she did not know that IU was a cost- per-individual incontinence revealed that the
disease. Based on research by Setiati and Pramantara, it average cost of individuals decreased by 23% per
was explained that in Indonesia urinary incontinence is decrease from seven incontinence episodes per week.24
often not reported by patients or their families. Health
authorities, both doctors and other medical personnel

Table 4: Descriptions of four factors which are Knowledge, Cultural, Educational, and Income Factors in
ten respondents
Initial Cultural
No. Knowledge Factors Educational Factors Income Factors
Name Factors
1. S As a result of giving birth, laugh Shy Upper secondary education Less Income
Think of not being a dangerous disease,
2. I Taboo Upper secondary education Less Income
drinking lots of water
3. M Due to drinking lots of water Shy Junior secondary education Income is enough
4. HN As a result of giving birth Shy Upper secondary education Income is enough
5. F Due to aging, lots of activity, sneezing Shy Upper secondary education Less Income
6. TH Due to aging, laugh Shy Upper secondary education Income is enough
7. RN Not a disease Shy Upper secondary education Less Income
8. R Due to cold, due to coughing and sneezing Shy Junior secondary education Less Income
9. A Due to a lot of activity, laugh Taboo Upper secondary education Less Income
10. NS Due to aging Shy Upper secondary education Less Income
The limitations of this study in the form of an 4. Abrams P, A W. Understanding Stress Urinary
interview schedule for informants were carried out Incontinence. In: Berlanij L, editor. Editions:
at the same time the informants were treated at RSHS Ismar Healthcare; 2004. 2; 19-86.
as patients so that there was the limited time when
5. Fernandes D,. Relationship Between Urinary
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Incontinence and the degree of depression in elderly
informants were also considered to be less
women: Sebelas Maret State University; 2010
comprehensive in answering the researchers’ questions
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results. Bump R, Obenchain R. Factors associated with
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Conclusion Womens Health. 2003; 12 (7): 687-98.
7. Fenner DE, Trowbridge ER, Patel DL, Fultz
Based on the description that has been stated, NH, Miller JM, Howard D, et al. Establishing
the conclusion is that there is a relationship between the prevalence of incontinence study: racial
knowledge, eastern culture with IU patients who do differences in women ‘s patterns of urinary
not seek treatment at the Hasan Sadikin Hospital clinic incontinence. The Journal of urology. J. Urol.
in Bandung. But there was no relationship between 2008; 179 (4): 1455-60
education level and income with IU patients who did not
seek treatment at the Hasan Sadikin Hospital polyclinic 8. BP Statistics. West Java Poverty Level September
in Bandung. The most dominant factor affecting urinary 2015. In: West BPJ, editor. West Java: Official
incontinence patients who do not go to the hospital is a Statistics News; 2016. p. 5.
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and a shame so it was necessary to disseminate Medicine Indonesia. 2008; 58 (7): 258-64.
information or counseling from the health staff to the
10. Balci E, Gürlevik Ö, Gün İ, Günay O. The effects
community, or mothers in particular, to be able to
of stress urinary incontinence on quality of life
educate them that if there were symptoms IU symptoms
in Turkish women in the reproductive age group.
should be able to immediately seek medical treatment or
Turkish Journal of Medical Sciences. TURK J
treatment.
MED SCI. 2012; 42 (5): 845-51.
Conflict of Interest: Nil 11. Sugiyono. Combined Research Methods (Mixed
Methods). Bandung: CV. Alfabeta; 2011. 12; 47-
Ethical Clearance: Not Required
52
Source of Funding: Self 12. Holroyd-Leduc JM, Straus SE. Management of
urinary incontinence in women: scientific review.
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18. Suparman E. Pathophysiology/Clinical
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DOI Number: 10.5958/0976-5506.2019.01637.1

Histopathological Changes in the Liver and Kidney of Albino

Mice on Exposure to Zinc Toxicity

Ishraq J. Hassan1, Ihsan S. Sahi2

1
Department of Physiology, 2Department of Surgery, College of Medicine, Misan University, Iraq

ABSTRACT
Background: Zinc is one of an essential trace element, it has an important role in many enzymes of the
body. It is less harmless in comparison with several other metal ions. Acute zinc intoxication occurs only
if there is an exposure to high doses of zinc. Zinc poisoning may be mostly from dietary supplements,
including multivitamins, or results from an accidental ingestion of zinc-containing household products.
Aim: The present study was designed to evaluate the histopathological changes of zinc toxicity in liver and
kidney of albino mice.
Materials and Method: Fourty-eight male Albino mice divided into four similar groups, the first
three
groups exposed during 15 days to different zinc concentrations in the form ZnSO4 (60 mg/kg, 80 mg/kg and
100 mg/kg) intraperitoneally. Fourth group set as a control group, treated with saline (0.9%) for the same
period of intraperitoneal injection. Sections of liver and kidney were stained with hematoxylin-eosin and
examined by light microscopy.
Results: Several changes in the liver and kidneys sections like cell necrosis, congestion, swelling,
disappearing of cell borders and others was observed during histopatological examination. It appears from
the results that the intensity of tissues defects increased with increasing of zinc toxic concentration.
Conclusion: Results of study suggest that zinc may be toxic for use in mice and cause many toxicological
changes in the liver and kidney.
Keywords: zinc sulfate, toxicity, mice, liver,
kidney
Inroduction eukaryotic cells, the physiologically Zn2+ concentration
is about 10 ng/L but if the level of zinc below 0.06 ng/L
Zinc is an essential micronutrient that almost
lead to trigger of apoptosis and when level rises
found in all tissues of the body and is important for
above
DNA synthesis, growth and differentiation of cell, in 60 ng/L toxicity can ensure6. Excessive zinc can cause
addition, zinc is essential for the immune system 1,2,3, as many problems in the body as the deficiency. The
protein metabolism so, it has an indispensable role for first signs of zinc toxicity include reduced feed intake,
human health4. Zinc is less harmless in comparison with reduced weight gain, bone resorption7, vomiting, nausea,
several other metal ions. Acute zinc intoxication occurs epigastric pain, fatigue and anemia6 and excessive Zn
only if there is an exposure to high doses of Zinc5. It has may reduce the absorption of calcium or phosphorus
recognized zinc deficiency for many years, but currently, [8]. Recent studies improved that free ionic zinc (Zn2+)
there are limited toxicological data available for zinc5. In is a powerful killer of neurons, glia and other cell
types6. In a study to Servet et al.9 on 119 autopsy cases
to determine the levels of toxic metals (cadmium and
Corrresponding Author: lead) and trace elements (zinc and copper) in the liver
Ishraq J. Hassan tissues, they found the average liver levels of metals and
Department of Physiology, College of Medicine, trace elements were found 29.5 µg/g, 216 µg/g,
Misan University, Iraq 0.39
Email: [email protected] µg/g and 4.38 µg/g dry weight for copper, zinc, lead and
cadmium, respectively. In other study about zinc
toxicity, Nilukshana et al.10 improved that when a person
attached
597 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 597

directly for any cause with zinc phosphide which is a conducted in this experiment approved by the local
rodenticide caused severe acute kidney injury, abnormal authorities (Faculty of Veterinary Medicine, Basrah
liver profile, pancreatitis and possible myocarditis. The University, Iraq).
renal biopsy revealed.
Design of the study: Forty-eight adult male albino mice
As the animal receives higher levels of zinc or toxic used for the study divided into four groups with 12 mice
amount for long periods of time, the animal will suffer in each. The first three groups were daily dosed via
from diarrhea, internal hemorrhage and even death7. The intraperitonial injection with 60, 80 and 100 mg/kg zinc
more remarkable pathological lesions of zinc poisoning in the form ZnSO4 for 15 days. An equivalent volume of
in liver and kidney were focal mononuclear degeneration, saline (0.9% NS) administered to the fourth group which
necrosis and derangement of liver and kidney6. Liobet et set as the control group.
al.11 studied the effect of subchronic oral administration
Histopathological examination: We took the sections
of zinc in Sprague-Dawley rats. Forty female rate
of liver and kidneys for histopathological preparation
were exposed to 0, 160, 320, and 640 mg/kg-day zinc
and examination. The samples collected and fixed in
acetate hydrate in drinking water for twelve weeks. The
10% buffered formalin. Each tissue trimmed to the
described renal lesions included flattened epithelial cells
thickness of 5mm in size, fixed and dehydrated in a
in the Bowmans capsule, desquamation of the proximal
series of alcohol concentration, and embedded in
convoluted tabulated tubule and pyknotic nuclei in
paraffin by using an automatic tissue processor. Then the
the tissue sectioned to a thickness of 5mm micrometer
640 mg/kg-day. Intraperitoneal administration of zinc on a microtome. After that, the liver and kidney tissues
may result an increase in liver mass due to hypertrophy mounted on the glass slide, de waxed and stained with
of the hepatocytes12,13. In other study of the effect of zinc hematoxylin and eosin (EH). Finally, we examined the
toxicity on the liver and kidney of rats for Emmanuel et liver and kidney tissues using 4x, 10x, and 40x
al.14the results were hepatic cells degeneration especially objectives for histological changes, depend on Hair-Bejo
at the portal areas of the livers and glomerular et al.13.
degeneration, mononuclear cells infiltration into the
interstices of the tubules and tubular necrosis of the rats
Results
kidneys15.
Figure (1) presents the liver section of the control
Aims of this study are:
group in which the mice exposed to 0.9% NS only. Note
1. To look at the importance of poisoning of the no observable microscopic lesions in the hepatic cells
zinc element and its impact on human and animal and the central vein of the liver. Figures (2-3) shows
health. changes of liver sections against zinc toxicity. The
results show that there were different stages of necrosis
2. Study of histopathological changes in liver
in the hepatic cell nuclei, swelling of hepatic cells,
and
congestion of the central vein, and there is a
kidneys because of zinc toxicity.
disappearance feature of some hepatic cells. So The
results explained that the worse histopathological
Materials and Method changes were direct proportion with increasing doses of
zinc.
All procedures conducted in this experiment were
approved by the local authorities (Faculty of Veterinary Figures (4) is a section of the kidney of mice set
Medicine, Basrah University, Iraq). as control croup which exposed to 0.9% NS, shows a
normal glomerulus in the Bowmamns capsule with
Experimental Animals: Forty-eight adult male albino
normal tubules. While the Figures (5-6) present the
mice, 12 weeks old and 20-25 g body weight. They were
results for changes of kidney sections against zinc
obtained from the animal house of the Animal House toxicity. They show that there were different stages of
of the Veterinary medicine College, Basrah, Iraq. They swelling in tubular cells that lead to narrowing of the
were housed in the Animal Room of the Veterinary tubular lumen, presence of a proteinous material in
medicine College, Basrah, Iraq, for 2 weeks before the the lumen of proximal and distal tubules, and also the
commencement of the experiment which lasted for 2 pictures show unclearance of the cell borders especially
weeks. The mice fed appropriately using standard mice in T3 group which treated with (100 mg/kg zinc).
chow and water provided ad libitum. All procedures
Fig. 4: kidney section of control group (0.9% N.S).
Fig. 1: liver section of control group (0.9 N.S). H&E 400X.
H&E 400X. Normal central vein ( ) and normal
Normal glumerulus ( ) and normal tubule ( ).
hepatic cell ( )

Fig. 5: kidney section of T1 treatment after 15 days

Fig. 2: liver section of T1 treatment after 15 days (60 (60 mg/kg zinc). H&E 400X.
mg/kg zinc). H&E 400X.
Swelling tubule ( ) and proteinous materials
Swelling hepatic cell ( ) and congestion central ( ).
vein ( )

Fig. 3: liver section of T3 treatment after 15 days Fig. 6: kidney section of T3 treatment after 15 days
(100 mg/kg zinc). H&E 400X. Congestion central (100 mg/kg zinc). H&E 400X.
vein ( ); inflammatory edge ( ); swelling Swelling tubule ( ), proteinous materials ( ),
hepatic cell ( ); necrosis hepatic congestion area ( ) and unclearance of cell
cell ( ), and disappearing the features of hepatic borders ( ).
cells ( )
Discussion 2. ODell B.L. History and status of zinc in nutrition.
Federation Proc.1984;43: 2821-2822.
The histo-pathological changes of the liver and
kidneys showed a vascular congestion. The result 3. Kincaid Z., DEMİR N., Abdennour C.,
showed also a swelling of the cells with cell necrosis BOUZERNA N. Effect of low dietary intake
represented by condensation, division and analysis of and experimental diabetes on the zinc and
the nucleus. It may result from the effect of zinc toxicity carbohydrate metabolism in rats. Turk J Med Sci.
on the thyroid gland causing hypothyroidism17 that leads 2002;32: 101-105.
to a decrease of the metabolism rate and then appearance
4. Plum L.M., Rink L., Haase H. The Essential
of hepatic changes, or due to a decrease of the blood
Toxin: Impact of Zinc on Human Health. Int. J.
stream because of anemia, secondary to hypocupremia
Environ. Res. Public Health. 2010; 7:1342-1365.
from zinc toxicity, which the commonest symptom of
the zinc toxicity18. The administration of the gradual 5. Fosmire G.J. Zinc toxicity. The American Journal
concentrations of zinc toxicity lead to the swelling of of Clinical Nutrition 1990;51: 225–227.
the tubular cells, appearance of the cells without the
6. Jerome N. Zinc Toxicity in Humans. School of
nucleus, which may be because of the accumulation of
Public Health, University of Michigan. 2007.
zinc-metallothionein complex19 after its reabsorption
Elsevier B.V. All rights reserved.
by the tubules in the kidney, and this complex analysis
by lysosome enzymes liberating the zinc ion which is 7. Kincaid R.L., Chew P.B., Cronrath D.j. Zinc
related again with the kidney’s metallothionein19. oxide and amino acids as sources of dietary zinc
for calves: effects on uptake and immunity. J.
The intensity of the toxicity increases with
Dairy Sci.1997; 80: 1381-1388.
increasing of the zinc dosed, and this leads to an increase
in the accumulation of the zinc ions in large quantities 8. Najafzadeh H., Ghoreishi S.M., Mohammadian
till they become more than the ability of the kidney to B., Rahimi E., Afzalzadeh M.R.,
form the metallothionein synthesis in the kidney is less Kazemivarnamkhasti M., Ganjealidarani H.
than in the liver19. Serum biochemical and histopathological
changes in liver and kidney in lambs after
Conclusion zinc oxide nanoparticles administration.
vetworld.2013; 534-537.
The present study highlights significant of hepatic
and kidney injury after acute zinc sulfate toxicity. We 9. Iritas S.B., Dinc A.H., Dip A., Unal B.M., Ertan
can conclude that the zinc toxicity cause B., Soylemezoglu T. Levels of toxic metals and
histopathological changes in the liver and kidneys, trace elements in autopsy liver tissue samples.
exacerbated by increased zinc concentration within the Medicine Science.2017;6(2): 242-8.
body. 10. Yogendranathan N., Sivasundaram T.,
Conflict of Interest: The researchers declares that there Constantine R., Kulatunga A. A case report of
is no conflict of interests with any other party. zinc phosphide poisoning: complicated by acute
renal failure and tubulo interstitial nephritis.
Source of Funding: This article is self- Funding BMC Pharmacology and Toxicology. 2017;18:
37.
Ethical Clearance: According to Scientific Research
Ethical Committee. ID: 1/19. Dated on 7.April. 2019. 11. Liobet J.M., Domingo J.L., Colomina M.T.
Email:[email protected] Subchronnic oral toxicity of zinc in rats. Bull
environ contam toxicol. 1988;41 :36-43.
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1. Christa F., Philip H. Low risk of adverse I., Abdrakmanov O., Ivanov L. Effect of
effects from zinc supplementation. The USAID cadmium and zinc ions on mitotic activity and
Micronutrient Program, 2005. protein synthesis in mouse liver. Medicina
(Kaunas).2005;41(6).
13. Hair-Bejo M., Saline S., Haifiza H., Julaida, 16. Dean C.E., Hargis B.M., Hargis P.S. Effects of
A. Inovo vaccination against infectious bursal zinc toxicity on thyroid function and histology in
disease on broiler chickens. J. Vet. Malaysia. broiler chicks. Toxicology Letters. 1991;57(3):
2000;12: 63-69. 309-318.
14. Tizhe E.V., Ibrahim N.D., Fatihu M.Y., 17. Johnsrud J., Abdallah A., Schichman S.A., Xiang
Onyebuchi I.I, George B.D.J., Ambali S.F., Z. Image Diagnosis: Zinc-Induced Copper
Shallangwa J.M. Influence of zinc supplementation Deficiency Causing Pancytopenia Recognized on
on histopathological changes in the stomach, liver, Bone Marrow Examination.. Perm J.2017; 21: 16-
kidney, brain, pancreas and spleen during 077.
subchronic exposure of Wistar rats to glyphosate. 18. Palmiter D.R. Protection against zinc toxicity
Comparative Clinical Pathology. 2014; 5:1535– by
1543. metallothioneine and zinc transport. PNAS. 2004;
15. Shilpa G., Rama N., Reddy A. Toxicological 101 (14): 4918-4923.
studies of zinc oxide nanomaterials in rats. 19. Hempe J.M., Cousins R.J. Cysteine–rich intestinal
Journal. Toxicological & Environmental protein and intestinal metallothionein: An inverse
Chemistry. 2012; relationship as a conceptual model for zinc
94:9. absorption in rats. J Nutr. 1992; 122: 89-95.
DOI Number: 10.5958/0976-5506.2019.01638.3

Microbial Inhibition to Water Hyacinth (Eichhornia Crassipes

[Martius] Solms-Laubach) in Abu Zirk Marsh by Using
Selected Fungi

Jameelah Wthaij Ogali Al-Yosef1, Abdul-Rahman Abduljabbar Al-Kubasi2, Ihsan Flayyih Hasan Al-
Jawhari3
1
Ministry of Science and Technology, Iraq; 2College of Science for women, University of Baghdad, Iraq;
3
College of Education for pure Sciences, University of Thi-qar, Iraq

ABSTRACT
Native fungi associated with water hyacinth have been identified and evaluated the potential of biological
control against waterhyacinth in Abu zirk marsh (south of Iraq).Twelve species of fungi associated
with different parts of the waterhyacinth (leaf, petiole) were isolated under sterile conditions in the
laboratory.These fungi belong to genera Ascomycota (Alternaria alternate, Stemphyllium sp,,Aspergillus
niger,A.flavus,A.ostianus,A.candidus,A.fumigatus,Penicillumfumiculosum.Trichodermharzianum,T.
lignorum,Basidiomycota (Rhizoctonia solani) Zygomycota(Rhizopus stolinifer) environmental parameters
such as temperature, relative humidity, pwere measured in field and in laboratory,the total occurrence of
fungi reached to (146 colony )A. alternata and R.solani was more frequency R.solani showed the severity
of disease 91.8%,and ability to change in the wet weight, number of leaves and the height of
plant.Thus,evaluated R. solani more effective and severe plant death. And can be developed as an effective
biological control.

Keywords: Mycoherbicide, water hyacinth, Native bioagent, Abu zirk marsh

Introduction river and parts of the Tigris river and attacked marshes,
Including Abu Zirk marsh, which exposed to the
Water hyacinth was found originally from the
invasion of water hyacinth in 2016.The amount of area
Amazon basin, and its entry into
infection with water hyacinth plants was about 2265875
Africa,Asia,Australia,and North America has been
Km2and thus the percentage reached to 18% [3].The
facilitated through human activities,is belongs to the
rapid and intensive growth of the water hyacinth plant
family Pontederiaceae, monocotyledon and aquatic
has caused environmental and economic damage in the
macrophyte, free floating with beautiful clusters of
marsh. The main objective of this study is development
violet and yellow flowers. Various methods to control
of an effective bio-control strategy for water hyacinth by
water hyacinth include manual, mechanical,chemical
using fungal pathogens as bioagents, in Abu Zirk marsh
and Biological control [1],which involves the use of
by isolating and diagnosing the native fungi associated
natural enemies (insects and fungal pathogens)[2].Fungal
with the water hyacinth and its pathogenic capacity. The
pathogens have gained acceptance as a practical, safe
article is the first study in the marshes of southern Iraq.
environmentally friendly. Various strains in the genera
Acremonium, Alternaria, Cercospora, and Myrothecium
Materials and Method
have been studied intensively as biocontrol agents and
shown to be effective under experimental conditions. Area Study: Abu Zirk marsh is located in Al-Islah
First appeared of Eichhornia crassipes in Iraq was in the District (50 km) east of Al-Nasiriya city. They were
mid-1980s, in Baghdad, after then spread to the Diyala located between latitude lines (33°00’-31°40’)
N, and between longitude lines(45°10’-48°14’) E.
The marshes are located in a natural depression of an
Corresponding Author: estimated size120 million cubic meters, and the marsh is
Jameelah Wthaij Ogali Al-Yosef filled with grasses of reed, papyrus and run through by a
Ministry of Science and Technology, Iraq stream of a head called Shatt Abu Lahya Figur( 1)
Email: [email protected]
602 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 602

stored on agar slants in 6 Co in a refrigerator.

Microscopic observation of each isolate was done with
an optical microscope at a magnification of40× and
fungal isolates were characterized morphologically
under a microscope based on their mycelium, fruiting
structures and spores and identified according reference
to the key of [5], The frequency of occurrence of the
isolates were rated as very frequent (>20%), frequent
(10%–20%) and infrequent (<10%) according to [6].
Figure 1: Abu zirk marsh (Google Earth, 2018)
Pathogenicity test: Young healthy leaves of water
Sampling Collected and Isolation Pathogen: Diseased hyacinth were washed under running tap water and then
water hyacinth leaves (showing browning, wilting, wiped with cotton swab dipped in 70% alcohol. The
yellowing, spots, blights, or combinations thereof) surface of leaves was injurey by pricking with a
were collected from water bodies in three sites within sterilized needle. One mycelial disc of 7days old culture
Abu zirk marsh this site called (1) Al-laghawat, site was placed on both injured and healthy leaf each, and
(2) Al-Rramid, site (3) Sayyid yashua. Infected leaves then covered these leaves with moist sterilized cotton.
were collected in sterilized plastic container. Isolation After these leaves were placed in a sterilized petri dish.
of the pathogen followed the standard procedure on At the bottom of the petri dish, sterilized moist filter
water hyacinth dextrose agar (WHDA) medium. The paper was kept. Plates were incubated at 25 C o. After
constituents were as follows (Water hyacinth leaves- verifying the disease on the health water hyacinth leaf,
200.0 g, Dextrose-15.0 g, Agar-agar- 20.0 g, Distilled the disease was tested on the growing water hyacinth in
water- 1000.0 ml, pH-5.6. Water hyacinth leaves plastic container measuring (45 cm, 35cm, 20 cm), was
(200 g) were washed in running tap water and then in kept in Marsh Research Center, Thiqar University. And
distilled water. These were boiled for 15-20 min in 500 fill a soil from the same sites was weighed with a
ml distilled water and filtered through thin gauze cloth kilogram of weight with field water 10 liters, and
for the collection of extract. The rest of the procedure provided with an oxygen compressors throughout the
was similar to the PDA pre-paration) [4]. The infected study period, plants were placed in a plastic container,
leaves were washed in running tap water to remove one plant homogeneous in weight and size as three
soil particles. The infected portions of leaf tissue were replicates for each plant. After
from the margins of necrotic or lesions cut into 3-mm 7days of acclimate follow the growth Characterizes had
pieces by using a sterile scalpel and surface-disinfected taken such as wet weight/gm, total length of plant/cm,
for one minute in 10% sodium hypochlorite. The tissue total length of root/cm, numbers of leaves/cm) addition
pieces were rinsed three times with sterile water and to the daily monitoring of air and water temperatures
dried with sterile blotting-pape. Four tissue pieces were and the relative humidity ratio. Corn oil emulsions
done on (WHDA) enriched with chloramphenicol (0.1 were prepared with 35% v:v corn oil amended with
mg/l) in order to avoid bacterial growth, pieces were 15% lecithin and 5% Tween 20, was diluted in sterile
aseptically transferred to the inoculated plates were distilled water containing the spores (at a concentration
incubated at 25Co for 3-5 days. The fungal colonies were of 1x104 spores/ml in the final oil-water emulsion) [7], 20
sub cultured individually by using a cork borer (5-mm ml of the suspension was applied on to water hyacinth
diameter) and transferred on to freshly prepared PDA leaves by using hand sprayers. The various plant species
media amended with in chloramphenicol (0.1 mg/l) were also left untreated as controls. Plants were rated
in for disease symptoms including leaf spots, leaf lesions,
80-mm Petri dishes. The plates containing each isolate and leaf death, and identification of the severity of the
were arranged in a completely randomized design. The pathogenicity of the selected fungus such as Alternaria
Petri dishes were checked for fungal growth after 4 -7 alternata and Rhizoctonia solani.
days and thereafter on a daily basis for 20–30 days. This
action was repeated three time until pure cultures were Statistical analysis: P<0.05 was chosen as a level of
obtained pure colonies of the isolates were grown by significance for all analyses. SPSS version 17.0 was
single-spore or hyphal-tip techniques. The isolates were used for all statistical tests (t- test)
Results and Discussion Rhizoctonia solani was more frequency(61.49%),also
Alternaria alternate reached to, (60%),but the frequency
Isolation of Fungi: Twelve fungal isolated from
of Penicillum fumiculosum (28.6%), Trichoderma
different parts in water hyacinth (leaves and petioel).
harzianum (12.87%), T. lignorum, Rhizopus stolinifer
These fungi belong to three genera. The common
reached to (8.58%),,Aspergillus niger, A.ostianus(5.7%),
genera was Ascomycetes ( Alternaria alternata,
A. flavus, A. candidus, A. fumigatus and Stemphyllium
Stemphyllium sp, Aspergillus niger, A.flavus, A.ostianus,
sp reached to (4.2%). For tests and evaluated of
A. candidus, A. fumigatus, Penicillum fumiculosum.
severity disease and determined as biocontrol agents
Trichoderma harzianum, T. lignorum the second genera
waterhyacinth. The statistical methods showed
was Basidiomycota (Rhizoctonia solani), and third
significant differenced were found between the A.
genera was zygomycota (Rhizopus stolinifer). The total
alternata (leaves), (petiol) and R.solani (leaves),
colony reached to (146 colony).Table (1 )showed
(petiol).
that

Table 1: Isolated fungal species associated with water hyacinth in Abu zirk marsh
S ( 1) Number S ( 2 ) Number S ( 3 ) Number Frequency
Fungal species Total Colony
P L P L P L %
Alternaria alternate 4 10 2 12 5 9 42 60 %*
Rhizoctonia solani 6 10 4 9 3 11 43 61.49%*
Penicillum fumiculosum 2 5 1 3 2 7 20 28.6%*
Aspergillus niger 0 1 0 1 1 1 4 5.7%*
A.fumigatus 0 1 0 1 0 1 3 4.2%
A.candidus 0 1 0 0 1 1 3 4.2%
A.flavus 0 1 0 1 0 1 3 4.2%
A. ostianus 0 1 1 1 0 1 4 5.7%
Trichoderma lignorum 1 2 0 1 1 1 6 .58%*8
Trichoderma harzianum 1 2 1 1 1 3 9 *% 12.87
Stemphyllium sp 0 1 0 1 0 1 3 4.2%*
Rhizopus stolinife 1 1 0 1 1 2 6 8.58%
Total 15 36 9 32 15 29 146
L)leaves,( p), Petoile, ( S)site, ( 0 )No recored, (*) significant p <0.05 )
The total occurrence of fungi colony reached to (146 chlorophyll concentration was( 35, 32, 35) respectively
colony).These are widely distributed taxa,. A alternata in the present study have also been reported from
has been described as a pathogen of water hyacinth in Yirefu [7]. The statistical method showed that significant
Bangladesh Australia, India and Egypt [8] in the present differences between treatment.
study have also been reported from El-Morsy
screened Table 2: Growth characters of water hyacinth as a
22 fungal isolates for their ability to infect waterhyacinth control Control
out of which Alternaria alternata, showed 79%, tissue Growth
Container Container Container
death after four weeks post inoculation[6]. In the present characters 1 2 3
study, Rhizoctonia solani has increased its susceptible of Air temperature 40 40 40
diseases severity to the water hyacinth compared with Relative humidity 17 17 17
the rest of the accompanying fungi. [9].
wet weight gm./m 2
105* 105* 105*
Pathogenecity test: Table (2) showed, the growth Plant height/cm 34 35 30
development of water hyacinth.The same wet weight Root length/cm 23 20 16
was selected in all treatments,with air temperature 40 °C Numbers of leaves
and relative humidity 17%. The other growth parameters *60 *57 *40
in plant/cm2
were different between the three treatments (1, 2, 3). The
Total Chlorophyll 35 32 *35
total plant height in treatments (1,2,3),were (34 cm,35
cm, 30 cm), root length (23 cm, 20 cm, 16 cm),Numbers (*) significant p <0.05
of healthy leaves were (60, 57, 40) and the total
Table (3) showed that R. solani was more effected plants, rather than producing new clones. Analysis of the
with treatment A.alternata in plant growth. The wet disease test results indicated that most fungal species
weight was deceased to 85gm/cm when comparative effect on water hyacinth. The results showed that there
with control (treatment 3). The statistical method were differences between isolates in the severity of the
showed that significant difference between these disease on the water hyacinth were recorded after 6
treatment, also plant height was 10 cm,but the numbers weeks of treatment in vitro. The severity of the disease
of infections leaves were increased to 53/m2 when for both Alternaria alternata and Rhizoctonia solani
compared with control,in the same time the chlorophyll has played an important role in reducing biomass (wet
concentration was decreased to 2,but the disease weigh) and plant growth number of leaves, daughters
severity was increased to 92.98% also the statistical plant. Alternaria alternata and Rhizoctonia solani as
method showed that significant differences between pathogens that will lead to a decrease in plant
these treatment. productivity of biomass. On the other hand, lead to
major changes in the physiological characters such as
Table 3: Growth characters of water hyacinth after low carbohydrate and chlorophyll and changes in water
treatment with Alternaria alternata and Rhizoctonia content. [11]. Refer that this fungus caused disintegration
solani of original water hyacinth mats into smaller mats,
Treatment stunted growth, decline in water hyacinth biomass,
Growth characters reduced flowering potential, reduced daughter plants
1 2 3
Air temperature ċ 40 40 40 production and finally rotting of the petioles followed by
Relative humidity 17 17 17 sinking.
wet weight gm/cm2 *94 *85 *120
Plant height/cm 15 10 37 Infected water hyacinth leaves showed necrotic
Root length/cm 23 19 17 type spots, zonate leaf spots and blight symptoms with
Numbers of infected leaves/m2 *52 *53 3 varying severities,
Total Chlorophyll 5 2 *33
Histopathology of plant tissue: Figure (2,3) showed the
disease Severity DS% 86 *92.98 *7.5
infection of water hyacienth by treatment with R.solani
treatment (1) A. alternata suspension, treatment and A. alternata and also the penetration of both fungi
(2) R. solani suspension, treatment (3 ) control (*)
the epidermis of the upper surface and the lower surface
significant p <0.05
of the leaf through the stomata and penetration of tissue
We have focused on two fungal pathogens petiole led to damage in the tissues of the palisade layer,
(Alternaria alternata and Rhizoctonia solani) isolated and the stability of the fungi in the aerenchyma tissue of
from diseased hyacinths to develop them as effective the leaf and tissues petiole,these infection with
agents in biological control. According to [10], the effect pathogenic fungi causes change in the size spongy
of mycoherbicide on water hyacinth can be determined layer compared to control,The Transmission Electron
based on its ability to limit host plant development, Microscopy (TEM) also demonstrates the stability of the
fewer living, leaves, and more death leaves on individual fungus hyphae of Rhizoctonia solani and spores of
Alternaria alternata

Figure 2: (A) Colony of Alternaria alternata on PDA ( B) Conidia of A.alternata under light microscope (C,
D) Alternaria alternata spores penetration the epidermis leave of water hyacinth and causing damage in
the tissue of leaf (E) TEM micrograph of a spores of A. alternata located in the intercellular space of water
hyacinth leaf (F) water hyacinth after infection with A.alternata.
Figure 3: (A) Colony of Rhizoctonia solani on pDA (B) hyphae of R.solani under light microscope (C) TEM
micrograph of a hypha of R.solani located in the intercellular space of water hyacinth leaf (D.E) Rhizoctonia
solani spores penetration epidermis leave of water hyacinth and causing damage in the tissue(F)water
hyacinth after infection with Rhizoctonia solani
Conclusion Taxonomic Review with Keys: Ascomycetes and
Fungi Imperfecti. 621 S., 39 Abb., 78 Tafeln.
Based on the current findings, we can conclude that, New York-London. Academic Press Inc. 1973.
Alternaria. alternata, Rhizoctonia solani, could be used
6. El-Morsy ME. Evaluation of microfungi for
as an effective bio control agent against water hyacinth
biological control of water hyacinth in Egypt.
following performance evaluation under natural
Fungal Diver. 2004, 16:35–51.
environmental conditions and their host specificity test.
7. Yirefu Firehun, Struik PC, Lantingaa EA, Taye
Conflict of Interest: None of the authors have any Tessema. Occurrence and diversity of fungal
conflicts of interest to declare. pathogens associated with water hyacinth and
their potential as biocontrol agents in the Rift
Source of Funding: The research was performed Valley of Ethiopia, Journal International of pest
independently, there is no funding, influence over study management, 2017 vol. 63,No.4,355-363
design, analysis, manuscript preparation, or scientific 8. Elwakil MA, Fayzalla EA, Sadik EA, Shabana YM.
publication. Biological control of water hyacinth with fungal
Ethical Clearance: The project was approved by plant pathogens in Egypt. In: Proceedings of the 7th
the International Symposium on Biological Control of
local ethical committee in University of Baghdad. Weeds (ed. E.S. Delfosse) Rome, Italy. 1989.
9. Opand GT, David M Musyimi, Hillary T
Nyanganga. Isolation and Identification
REFERENCES
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Evaluation of ratio variation of water hyacinth in the Winam Gulf (Lake Victoria, Kenya). IOSR
(Eichhornia crassipes) on the production of pig Journal of Agriculture and Veterinary Science
dung biogas. Int. J. Biol. Sci., 2013, 2: 44-48. (IOSR-JAVS) e-ISSN: 2319-2380, p-ISSN: 2319-
2. Firehun Y, Struik PC, Lantinga EA, Taye 2372. 2017. Volume 10, Issue 8 Ver. I
T.Joint use of insects and fungal pathogens in (August
the management of water hyacinth (Eichhornia 2017), PP 39-43
crassipes): perspectives for Ethiopia. J Aquat 10. Shabana YM. The use of oil emulsions for
Plant Manage. 2013, 51:109–121 improvising the efficacy of Alternaria
3. Marshlands Rehabilitation Center and wetland of eichhorniae as a mycoherbicide for water
Iraqi. Report, to the Ministry of Water Resources hyacinth (Eichhornia crassipes). Biol. Control.
Iraq. 2018. 2005, 32 (1): 78-89.
4. Aneja KR. Experiments in Microbiology, Plant 149:21-27
Pathology and Biotechnology. 4th ed. New Delhi: 11. Julien MH, Griffiths MW, Stanley JN. Biological
New Age International Publishers. 2003. control of water hyacinth: The moths
5. Ainsworth GC, Sparrow FK, Sussman AS. Niphograpta albiguttalis and Xubida infusellus:
The Fungi, an Advanced Treatise. Vol. IV A: biologies, host ranges, rearing, releasing and
A monitoring techniques. ACIAR Monograph, 2001.
pp. 79-91
DOI Number: 10.5958/0976-5506.2019.01639.5

Complications and Lipid Parameters Status among 50 Years

and above Age Group Hypertension Population at Primary
Health Care Centres of Buraidah City

Asim Fahad AlKhalifah1, K. Chandra Sekhar2, Abdulaziz Sulaiman Alsaif3, Alya fahad Alkhalifah4
1
4th Year (R4) Family Medicine Resident at Saudi Board Family Medicine, Al Qassim Province,
KSA.;
2
Professor & Faculty at Hay Al Akhdar Post graduation Training Centre for Saudi Board of Family
Medicine, Buraidah, Qassim Province, Saudi Arabia; 34th Year (R4) Family Medicine Resident at Saudi
Board Family Medicine, Al Qassim province, KSA.; 4Final Year College of Dentistry, Buraidah private
colleges, Buraidah

ABSTRACT
Background: As we all know that Hypertension problem increasing in all over the world. Being Family
Medicine specialists, in addition to detection of hypertension problem at early stage and also need to focus
more and more on complications identification at the earliest and suggesting proper remedial and life style
measures periodically insisting and educating them, minimizing the burden on spending amount by the
government and also good quality of life of the individual.
Objectives: To identify the complications of hypertension and lipid profile status among study population.
Materials & Method: A cross sectional institutional based record review study conducted at primary
health centers of Buraidah City from January 2018 to June 2018 among 170 persons records 50 years old
and above in the concerned primary health care centers. After getting institutional ethical committee
clearance, data entered in Statistical package for Social Sciences (SPSS) and necessary statistical tests like
simple proportions and chi square tests were applied.
Results: In the study population, about 47.7% were having abnormal triglycerides. among the abnormal
triglycerides study group, the prevalence of hypertension with complications was 33.3%. About 20.6%
(35/170) individuals were having different complications. Of which, Ischaemic heart disease (IHD) was
identified as common complication which accounts 15.3% of all complications noticed in the study
population.
Conclusions: Based on the study results, majority of the people were having abnormal lipid parameters
and most common complication identified in the study population was ischaemic heart disease. Need
strategies to identify the complications at the early stage at primary health care centers for the guidance in
the management of the complications.

Keywords: Triglycerides, serum cholesterol, complications, annual health check

up.
Introduction
The rampant increase of hypertension in the society
is due to undergoing socioeconomic and epidemiological
transition, increasing life expectancy is burdened with
Corresponding Author: increasing prevalence of hypertension in urban areas,
Dr. K. Chandra Sekhar, due to urbanization, less physical activity,unhealthy life
Professor & Faculty style and stress. Hypertension as a significant cause of
Hay Al Akhdar Post graduation Training Centre for serious health complications, morbidity and mortality
Saudi Board of Family Medicine, has been recognized in most nations globally particularly
Buraidah, Qassim Province, Saudi Arabia in the Western world. It is currently estimated that
Email: [email protected]
hypertension affects more than a quarter of the world
adult population
607 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 607

including the Kingdom of Saudi Arabia. It contributes and situations, the following research was carried out
to the burden of heart disease, stroke, Kidney failure, to determine the complications of hypertension and
hypertensive retinopathy, premature mortality and together with the associated lipid profile status among
disability. According to the World Health Organization individuals records at the primary health care centers of
global fact sheet on global burden of diseases, increased Qassim region. Gravity of complications that cripple the
blood pressure was one of the leading causes of death person in physical, mental agonies and leads to drain the
and disabilities globally in 20141. family and country resources.

The Kingdom of Saudi Arabia government has been

Aims and Objectives
increasing funds allocated to the health care sector in
the past decade with about $ 61 billion in 2011 which 1. To identify the complications of hypertension
was 12% of the entire national budget and 5 % of the in
entire gross domestic product in the year 2014with a the study population.
health per capita of approximately $ 2500 in the same 2. To find the lipid profile parameters association
year based on world bank values 2. The healthcare with hypertensive population.
burden is expected to increase owing to the expanding
population, increasing number of elderly persons and the 3. To know the annual check up status in
development of related lifestyle diseases such as obesity, hypertensive
hypertension and cardiovascular complications. population.

Hypertension is one of the leading causes of

Materials and Method
morbidity, mortality and socioeconomic burdens
worldwide particularly among persons above 55 years Study Design and Setting: This was a institutional
where its prevalence is between 51-70 % in Saudi based record review cross sectional study carried out in
Arabia. In terms of associated life complications, the primary health care centres (PHCC) in Buraidah city.
hypertension caused about 50% of stroke, heart failure There are 44 primary heath care centres in the city all
and heart diseases in addition to another 40% deaths are functioning and providing the services to the needed
among diabetic patients globally in 2013. The highest people of Buraydah city.
number of complications arising from hypertension are
mainly cardiovascular and include conditions like Study Period: This study was conducted from 1st
myocardial infarction, heart failure, cerebrovascular January 2018 to 30th June 2018.
accidents together with visual disturbances, and kidney
problems3. Target Population: All patients above 50 years old
visited to the Primary health centre (Based on
The complications arising from hypertension in availability of the records).
addition to the disease itself creates a huge economic
stress on the affected individuals and their families, Sample Size Calculation: Meta-analysis of prevalence
national health systems, countries and the world of hypertension in Saudi Arabia among above 50 years
at large. It is therefore, an modern epidemic in the age group was reported as 51% per cent. This prevalence
public healthcare sector. The global costs for treating is considered to find out the sample size in my study.
hypertension and its complications assessed in various Finally sample size arrived 170 by using the formulae of
world Bank region was estimated to be about $370 4pq/l2 in qualitative studies.
billion which is about 10 % of the overall world budget.
The Eastern European regions and Asia spends Sampling Method: Simple random sampling method.
about
20% of their total budget on high blood pressure and the Sampling Procedure: Out of 44 primary health care
associated sequelae. Even though the developed nations centers in Buraidah City,10 PHCC were selected
and high–income countries have the largest share in randomly. As per the requirement, 17 patients records to
hypertension spending, there is continuous increase in be collected from each PHC. The selection of the
the expenditure among the developing nations as well.4 records also used by simple random method. After
selection of the record, verified all my study variable
It is widely accepted that cardiovascular disease and filled in our questionnaire. The pilot study was done
is associated with hypertension and increased blood on 34 samples. Same process was used to complete the
levels of lipids. In relation to the above study requirement of the sample size of 170.
results
Exclusion Criteria: Hypertensive patients less than 50the director of PHC and file room manager and taken
years. appointment and explained in detail about the purpose
and methodology of the present study and assured strict
Ethical Clearance: Regional Research Ethics
confidentiality of information. First 10 PHC selected
Committee -Qassim Province, issued the ethical
randomly to initiate the study. From the each PHC, 17
clearance certificate to initiate this study.
files were selected by simple random method. The pilot
Method of Data Collection: An questionnaire was study conducted among 34 samples from 2 PHCs.
prepared based on the availability of information in
Data Analysis: Statistical analysis was done by using
the records of hypertension files in PHCs and also
the statistical software spss -21.0 version. Necessary
taken consultation and discussion with the experts
statistical tests like simple proportions, chi square tests
in the department and under supervision of the guide.
were applied for inferential statistical interpretation.
One day before visited to the concerned PHC and
met

Results

Table 1: Lipid profile parameters association with Hypertension study population (n = 113)

Hypertension without Hypertension with

Triglycerides Total P value
complications complications
Normal 50 (84.7%) 9 (15.3%) 59 (100%)
X2-5.07, 1df,
Abnormal 36 (66.7%) 18 (33.3%) 54 (100%)
P-0.02
Total 86 (76.1%) 27 (23.9%) 113 (100%)
Serum cholesterol P value
Normal 74 (74.7%) 25 (15.3%) 99 (100%)
X2-2.35, 1df,
Abnormal 33 (86.8%) 5 (13.2%) 38 (100%)
P-0.12.
Total 107 (78.1%) 30 (21.9%) 137 (100%)

Table 1 revealed that in the study population, among the abnormal triglycerides study group the prevalence of
hypertension with complications was 33.3% and normal triglycerides study group, the prevalence of hypertension
with complications was 15.3%. In the study population, among the abnormal cholesterol study group the prevalence
of hypertension with complications was 13.2% and normal cholesterol study group, the prevalence of hypertension
with complications was 15.3%. As the sample is small and also having complications sample also very less and
hence statistical applications may be inappropriate.

Table 2: Type and duration of complications in study population

Type of complication Number Percentage
Retinopathy 7/170 4.1%
Stroke 2 1.1%
IHD 26 15.3%
Total 35 20.6%
Duration of complications
< 5 yrs 16 45.7%
5-10 yrs 15 42.9%
> 10 yrs 4 11.4%
Total 35 100%
Table 2 highlighted that in the study population about 20.6% (35/170) individuals were having different
complication. Of which, ischaemic heart disease (IHD) was identified as common complication which
accounts
15.3% of all complications noticed in the study population. In the study population, 42.9% of complications reported
between 5-10 years of the duration.

Table 3: Health education versus Hypertension (n = 168)

Health education Hypertension without complications Hypertension with complications Total
Yes 123 (79.3%) 32 (20.7%) 155 (100%)
No 12 (92.3%) 1 (7.7%) 13 (100%)
Total 135 (80.3%) 33 (19.7%) 168 (100%)

Table 3 depicts that in the study population, about 92.2% (155/168) were received health education. Of which
about 20.7% were having hypertension with complications.

Table 4: Annual health Check up versus Hypertension (n = 169)

Hypertension without Hypertension with
Annual health Check up Total
complications complications
Yes 114 (79.7%) 29 (20.3%) 143 (100%)
No 20 (76.9%) 06 (23.1%) 26 (100%)
Total 134 (79.2%) 35 (20.8%) 169 (100%)
Table 4 revealed that in the study population, about improvement. Study conducted in Bangladesh by C. M
84.6% (143/169) were received annual health check up. Reza Qureshi Forhad, Asma Kabir et al 5 revealed that
Of which about 20.3% were having hypertension with it was a cross sectional study in which 159 diagnosed
complications. hypertensive patient and 75 with normal blood pressure
(normotension) were enrolled for comparison. These
Discussion patients sought a through health cheek up including
blood pressure assessment between May 2012 to
The present cross sectional record review study was April
conducted at different primary health care centres to 2013 in Tairunnessa Memorial Medical College and
study the complications of hypertension and lipid profile Hospital. Lipid parameters total cholesterol (TC),
status association with hypertension in Buraidah city. In triglyceride (TG), low density lipoprotein ( LDLc) and
the present study, among the abnormal triglycerides high density lipoprotein (HDLc) were estimated by
study group the prevalence of hypertension with enzymatic colorimetric test. Study revealed the results of
complications was 33.3%. There was statistically the mean of Systolic blood pressure and Diastolic blood
significant association was observed between pressure of hypertensive were higher than normotensive
triglycerides status and hypertension complications (p<0.001). The serum levels of total cholesterol,
(P<0.05). In the study group, among the abnormal triglyceride and LDL-C in hypertensive subject were
cholesterol study group the prevalence of higher than normotensive persons and statistically
hypertension with complications was significant (p<0.001).
13.2%. As the study record based review study and
some records were not having all the parameters. As the
The logistic regression analysis indicates
sample size is small and due to not available of other
hypertensive were 1.2 times higher total cholesterol, 1.3
lipid parameters not interpreted in the study. In the
times higher triglyceride and 1.2 times higher LDL-C
present study, lipid abnormality individuals itself is less
and one of the limitation of the present study findings than normotensive persons and was statistically
cannot be generalized into the entire Buraidah significant (p<0.001). Another study conducted in
population. Riyadh, Saudi Arabia by Abdalla A Saeed et al 6 with
background of this study aims to assess the association
But record review studies sometimes will act as between lipid profile and obesity among adults in
eye opener for the better planning strategies for the Kingdom of Saudi Arabia
and identify anthropometric predictors of dyslipidemia. In the present study, about 84.6% were receiving
overall prevalence of obesity ranged from 33.8 to annual health check up. study done in Aseer region by
44.4 Al- Khaldi, Yahia M et al revealed that the rate of
% and the overall dyslipidemia prevalence ranged from defaulter was high, which indicated an ineffective recall
about 25 to 44% depending on type of dyslipidemia system. A high percentage of patients did not have
and anthropometrics used. Prevalence of dyslipidemia annual checkups because of assumption of the lack of
and mean concentration of lipids profile were generally laboratory facilities and poor coordination with
significantly higher in obese than non obese. About hospitals. study revealed that the majority of
45.7% of complications occurred in < 5 years hypertension patients had poorly controlled and
duration reason could be multifactorial
of hypertension. 9,10
. In spite of providing all basic health services at
In the present study, about 20.6% (35/170) the primary health care centres timely improvement,
individuals were having different complications. Of quality annual checkups and timely laboratory facilities,
which, ischaemic heart disease (IHD) was identified patient and health care team attitude towards regular
as common complication which accounts 15.3% of all treatment, identification of the complications, record
complications noticed in the study population. Another maintenance and goal towards increase life expectancy
study on complications and hypertension conducted to be developed and ultimately minimizing the wasteful
in Saudi Arabia by M. E. K. Ahmed and I. B. El- resources and cost effectiveness. Need large sample
Awad 7 carried out a cross-sectional study involving similar studies are required to substantiate the present
known hypertensive patients so as to find out about its study findings.
complications. WHO Stage II and Stage III total organ
complications were evident in 37.1% of the patients. Conclusions
From the study, mild-retinopathy accounted for 21.6%,
Based on the study results, number of hypertension
followed by albuminuria (15.1%), urea elevation of
complications people itself is less. Among them,
more than 50mg/dl in 12.9% of the patients and 10.3%
ischaemic heart disease (IHD) was identified as common
had left ventricular hypertrophy and these were the most
complication which accounts 15.3% of all complications
common stage II complications 7. Complications record
noticed in the records. Among the hypertensive
availability at specialist hospitals is different from
individuals, lipid profile abnormality was more. Not
complication record at primary health centres. As more
only hypertension and even hypertension complications
specialist availability and competency and laboratory
itself exhibits as a “ice berg phenomenon of the
facilities availability at primary health centre is different
disease”.
from the specialist hospitals. Family Medicine specialist
introduction and periodical trainings and exposure Source of Funding: None.
certainly make some difference in complications
diagnosis, management and records maintenance in the Conflict of Interest: None.
coming days. Ethical Clearance: Institutional ethical Committee
In the study population, about 92.2% (155/168) clearance taken.
were receiving health education. Study conducted in
Makkah region highlighted about health education REFERENCES
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elevated blood pressure should be made through an 2. Samargandi TH. The Attitudes of Saudi Teachers
efficient system of follow up in the PHCC centers Toward Teaching Physical Education for Girls at
through effective health education about the disease and Public Schools in Jeddah, 2015.
also about possible complications of hypertension 8. 3. Saudi Hypertension Management Society
Education also one of the important tool for bringing (2018). Saudi Hypertension Guidelines 2018.
many changes in the health seeking behaviour of the doi:161020170004948.
individuals.
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 611

4. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller Eastern Mediterranean health journal= La revue
AB, Daniels J, Gülmezoglu AM, Temmerman de sante de la Mediterranee orientale= al-Majallah
M, Alkema L. Global causes of maternal death: al-sihhiyah li-sharq al-mutawassit. 2001;7(4-
a WHO systematic analysis. The Lancet Global 5):689-96.
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5. Forhad CR, Kabir A, Biswas T, Choudhury in primary health care centers in Makkah district,
KN, Rahman MZ, Hussain DA, Ghosh SK. Saudi Arabia. Journal of family & community
Status of Lipid Profile among the Hypertensive medicine. 2000 Sep;7(3):23.
Patients in Bangladesh. University Heart Journal.
9. Al-Khaldi YM. Quality of hypertension care in
2014;10(2):73-7.
the family practice center, Aseer Region, Saudi
6. Saeed AA. Anthropometric predictors of Arabia. Journal of Family and Community
dyslipidemia among adults in Saudi Arabia. Medicine. 2011 May;18(2):45.
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MZ, Khan NB, Al-Mazrou YY, Al-Maatouq MA,
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DOI Number: 10.5958/0976-5506.2019.01640.1

Cardiac Failure in Misan, Iraq

Khalid Obaid Mohsin

M.B. Ch. B., C.A.B.M, D.M., Head of Internal Medicine Department, College of Medicine,
Misan University, Misan, Iraq

ABSTRACT
Background: Categorization of heart failure patients depending on left ventricular ejection fraction (by
using echocardiography) is important because there are different causes, comorbid conditions, and response
to management. In addition, identifying and treating these comorbidities are the main steps in managing
patients with heart failure.
Objectives:
z To determine the types and stages of heart failure in Misan.
z To determine its comorbidities, consequently, reaching better management and prognosis.
Patients and Method: A cross-sectional study was conducted in Al-Sader Teaching Hospital from October
2017 to February 2018. A total number of 60 patients were diagnosed as HF cases according to the full
workup (including history, thorough clinical examination, Chest x-ray, electrocardiography, and
echocardiography).
Results: A total of 60 patients were diagnosed as heart failure. The distribution of patients was equal in
both genders with a predominance of patient aging more than 60 years. Approximately, half of the patients
had heart failure with reduced left ventricular ejection fraction and stage D. As comorbidities; about three-
quarters of patients had hypertension followed by diabetes mellitus and coronary artery disorders.
Conclusion: The incidence of heart failure and comorbid conditions are increasing with age. The presence
of comorbidities is more with the progression of stages in heart failure. Therefore, a frequent medical
follow up with 2-Dimensional Echocardiographic evaluations should be encouraged, especially, with older
patients.

Keywords: heart failure, stages, Misan, Iraq

Introduction decreased ability to exercise, and leg edema. The
dyspnea is usually getting worse while doing exercise,
Heart failure (HF) is a clinical syndrome and can be
lying down, and can awake the patient at night (3, 4).
defined as the inability of the heart to pump adequately
to maintain a blood flow that can meet the total needs of The ejection fraction is usually used to determine
the body and usually, referred to as a congestive HF (1, 2)
. the pumping effectiveness of the heart, as well as, to
classify the types of HF. Additionally, it can indicate the
Commonly, patients with HF present with dyspnea, severity of HF (5). Therefore, the categorization of HF
tachypnea, tachycardia, fatigue, excessive tiredness, patients depending on left ventricular ejection
fraction
(LVEF) is important because there are different causes,
Corresponding Author: comorbid conditions, and response to management (6).
Dr. Khalid Obaid Mohsin
M.B. Ch. B., C.A.B.M, D.M., At 2016, European Society of Cardiology classified
Head of Internal Medicine Department, HF into three types according to LVEF (7):
College of Medicine, Misan University, Misan, Iraq z HF with preserved LVEF (≥50%).
Phone: 00964775556641
z HF with mid-range LVEF (40–49%).
Email: [email protected]
[email protected] z HF with reduced LVEF (<40%).
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 613

Moreover, the New York Heart Association Exclusion criteria: any other diagnosis other than
classified HF into 4 stages: Stage A, B, C, and D HF. In addition, any case rejected to be involved in this
depending on the objective assessment (8). study or did not complete the follow-up evaluations was
Furthermore, the comorbid conditions are highly excluded.
important in patients with HF and may have a role in The study protocol was reviewed; ethical approval
the treatment decision for HF (some medicines that
and official permission were obtained from Ministry of
are used in HF treatment may lead to worsening the
Higher Education, College of Medicine in Misan, Misan
symptoms and exacerbating the condition of HF). It
directorate of health and Al-Sader Teaching Hospital
is well recognized that HF with preserved LVEF is at
to carry out this study. Informed written consent was
more occurrence of comorbidities than HF with reduced
obtained from each patient or from their parents. The
LVEF. So, identifying and treating these comorbidities
are the main steps in managing patients with HF (9). analysis of data was carried out using Microsoft Excel
and was presented in form of tables that interpreted by
For these reasons, this study had arisen to study the numbers and percentages.
HF in Misan province, classifying those patients and
to identify their comorbidities, consequently, reaching Results
better management and prognosis.
A total of 60 patients were diagnosed as HF. The
Patients and Method distribution of patients was equal in both genders with
a predominance of patient aging more than 60 as shown
A cross-sectional study was conducted in Al-Sader
in table 1.
Teaching Hospital in Misan province (South East Iraq)
during a period of four months from October 2017 to Regarding echocardiographic finding in this study; the
February 2018. patients were classified depending on LVEF. Half of the
patients had HF with reduced LVEF and only 10 (16.7%)
The patients were selected from the out-patient
department, from the echocardiographic unit, and from had HF with preserved LVEF as shown in table 2.
the in-patient medical department. A total number
Approximately, half of the patients had stage D
of
followed by C and B stages reaching (35.0%) and
60 patients were diagnosed as HF cases according to
(15.0%) respectively as shown in table 3.
the full workup (including history, thorough clinical
examination, Chest x-ray, electrocardiography, and Regarding comorbidities associated HF;
echocardiography). The required data was collected approximately, three-quarters of patients had
through face to face interview with patients. hypertension followed by diabetes mellitus and
Finally, an echocardiographic imaging study was coronary artery disorder reaching (53.3%) and (48.3%)
done for all patients by a specialist doctor. The first respectively as shown in table 4.
echocardiographic evaluation was done to confirm
the diagnosis of HF followed by a second detailed Table 1: General characteristics of patients with HF
echocardiographic evaluation after the patient was
Characteristics Number (%)
stabilized.
Age in years:
Echocardiographic imaging was performed with < 60 10 (16.7%)
GE machine, model vivid, version E9 following the > 60 50 (83.3%)
recommendations and the guidelines of American Gender:
Society of Echocardiography (10). Categorization and Male 30 (50.0%)
staging of HF were done for every patient following the Female 30 (50.0%)
recommendations and guidelines (7, 8).
614 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
Table 2: Classification of HF patients depending on prevalence of HF with preserved LVEF increased
LVEF that determined by echocardiography significantly in the last decades (13) but the present
study revealed that half of the patients had HF with
Types of HF Number (%)
reduced LVEF and only 16.7% had HF with preserved
HF with preserved LVEF 10 (16.7%)
LVEF. These rates were different from other studies
HF with mid-range LVEF 20 (33.3%)
which reported about 30–55% of patients had HF with
HF with reduced LVEF 30 (50.0%) preserved LVEF (14, 15). Nevertheless, more morbidity and
Total 60 (100%) mortality were reported in HF patient with preserved
LVEF than those of reduced LVEF (15, 16).
Table 3: Stages of HF patients depending on the
The presence of comorbid conditions was more with
objective assessment
the progression of stages in heart failure. Additionally,
Stages of HF Number (%) imaging studies, especially, the 2-Dimensional
Stage A 1 (1.7%) Echocardiography was essential in categorizing and
Stage B 9 (15.0%) staging the cases of heart failure.
Stage C 21 (35.0%) Approximately, the vast majority (70.0%) had
Stage D 29 (48.3%) hypertension in this study followed by diabetes mellitus
Total 60 (100%) and coronary artery disorder reaching (53.3%) and
(48.3%) respectively. The same sequence of commonest
Table 4: Cardiac and non-cardiac comorbidities in comorbid condition was seen with a similar study in
patients with HF Brazil but with fewer rates (17).
Comorbid condition Number (%) Some patient had one or two combined diseases or
Hypertension 42 (70.0%) more together and this would increase the morbidity and
Diabetes Mellitus 32 (53.3%) make a worse prognosis.
Coronary artery disorder 29 (48.3%) It is of note that such diseases like hypertension,
Rheumatic fever 13 (21.7%) diabetes mellitus, and coronary artery disease are usually
Atrial fibrillation 13 (21.7%) increasing with aging and most of the patients in the
Chronic obstructive pulmonary disease 12 (20.0%) current study were older than 60 years so more risk to
Chronic renal failure 10 (16.7%) have HF and more risk for comorbidities, subsequently,
Cerebrovascular accident 9 (15.0%) poor outcome.
Anemia 7 (11.7%) In addition, this study revealed the presence of
Metabolic syndrome 5 (8.3%) non-cardiac diseases like renal, metabolic, anemia, and
Thyroid disease 1 (1.7%) thyroid disease associated with HF. It was found that
even the non-cardiac comorbidities would increase the
Discussion risk of death, particularly, in HF patient with preserved
LVEF (13, 18).
The current study revealed that there was more risk
of developing HF with increasing age of patients in A further study to follow up those patients to report
which there were 50 cases (of total 60) older than 60 their outcome is recommended in the future.
years and this was in accordance with different studies (11,
12)
. Conclusion
Additionally, this study showed that the distribution The incidence of heart failure and comorbid
of patients was equal in both genders whereas Gerber et conditions are increasing with age. The presence of
al study reported a predominance of the male gender in comorbidities is more with the progression of stages
HF cases, especially, in HF with reduced LVEF (12). in heart failure. Therefore, a frequent medical follow
up with 2-Dimensional Echocardiographic evaluations
Regarding echocardiographic finding in this
should be encouraged, especially, with older patients.
study;
the patients were classified depending on LVEF. The
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 615

Conflict of Interest: No conflict of interest comorbidities drive myocardial dysfunction and

remodeling through coronary microvascular
Source of Funding: Not funded.
endothelial inflammation. J Am Coll Cardiol.
2013;62(4):263–71.
REFERENCES
10. Hahn RT, Abraham T, Adams MS, Bruce CJ,
1. Tavazzi L. Towards a more precise definition Glas KE, Lang RM, et al. Guidelines for
of performing a comprehensive transesophageal
heart failure aetiology. Eur Heart J; 2001; 22: echocardiographic examination:
194–5. recommendations from the American Society of
2. Zile MR, Baicu CF, Bonnema DD. Diastolic Echocardiography and the Society of
heart failure: definitions and terminology. Prog Cardiovascular Anesthesiologists. J Am Soc
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structure and function in heart failure. Eur Heart 14. Hogg K, Swedberg K, McMurray J. Heart failure
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current state and future directions. JACC Hear Roger VL, Redfield MM. Trends in prevalence
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DOI Number: 10.5958/0976-5506.2019.01641.3

Dilated Cardiomyopathy in Children

Khalid Obaid Mohsin

M.B. Ch. B., C.A.B.M, D.M., Head of Internal Medicine Department, College of Medicine,
Misan University, Misan, Iraq

ABSTRACT
Background: Dilated cardiomyopathy in pediatrics age group is considered as a serious problem
with
variable prognosis. There are few studies for this issue in Iraq and no previous local study.
Objectives:
z To determine the associated risk factors, clinical presentation in dilated cardiomyopathy.
z To determine its characteristic electrocardiographic and echocardiographic findings.
Patients and Method: A hospital-based cross sectional study conducted during a period of three years
from 2009 to 2012 in Misan, Iraq. The diagnosed cases of dilated cardiomyopathy were selected from
the referred patients for an echocardiographic evaluation in Al-Sader Teaching Hospital with suspicion of
either dilated cardiomyopathy or heart failure. A full history, thorough clinical examination, Chest X-ray,
electrocardiography, 2D-Echocardiography were done for all cases.
Results: Children with dilated cardiomyopathy presented with variable symptoms but congestive heart
failure was the most common. Male was more predominant than female with median age of 11 ± 2.605
years. Different electrocardiographic findings but tachyarrhythmia was the commonest.
In echocardiography, left atrial size was positively correlated with left ventricular function and the majority
had mitral valve regurgitations.
Conclusion: Dyspnea and heart failure were the most common presenting symptoms in children with
dilated cardiomyopathy. NYHA class III heart failure was common causing more morbidity and mortality
in those patients. Additionally, imaging studies, especially, the 2-Dimensional Echocardiography was
essential in confirming the diagnosis.

Keywords: Dilated cardiomyopathy, children,

Misan
Introduction usually presented with progressive heart failure with
insidious onset but may present as acute onset in about
Dilated cardiomyopathy (DCM) is the commonest
25% of patients, if associated with lower respiratory
type in pediatrics (1). The incidence in children is
infection (2). Cough, shortness of breath, wheezing,
reported to be 0.34 to 0.73 per 100.000 per a year (2)
irritability, and poor feeding are usually the primary
while in adult; it was found to be 6.95/100.000 per a
symptoms. Easy fatigability, growth failure, decreased
year as reported by another study in Europe (3).
urine output, and pallor may occur (4). Other clinical
Patients with DCM is
presentations which occur in about 20% of patients
are the following: palpitation, chest pain, orthopnea,
Corresponding Author: Dr. hemoptysis, abdominal pain, neurologic deficit, and
Khalid Obaid Mohsin M.B. syncope (4). About half of cases of DCM are preceded
Ch. B., C.A.B.M, D.M., by a history of upper respiratory tract infection which
Head of Internal Medicine Department, is usually of viral origin (5). Coxsackie B (serotypes 1
College of Medicine, Misan University, Misan, Iraq to 6) is the commonest virus causing DCM in children.
Phone: 00964775556641 Other viruses such as enterovirus, adenovirus, influenza,
Email: [email protected]
617 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 617

and rubella are implicated in myocarditis (5). In addition, NYHA 2: ADSP at usual/ordinary physical activity.
familial cardiomyopathy is positive in about 25% of
patients (6). NYHA 3: ADSP at less than usual physical

Sometime, DCM is misdiagnosed in pediatrics activity. NYHA 4: ADSP at rest or with minimal
age group as an upper respiratory tract infection and
activity.
patient may receive false management for a long time
(7)
. Moreover, DCM has substantial morbidity, as well Inclusion criteria: age is between 1-12 years,
as, mortality (8). Initially, it is well known that one-third both
of affected DCM cases would die, other third would gender, symptomatic, all patients had left ventricular
improve, and the last third would have a chronic disease 2D- ejection fraction (2D-LVEF) < 0.45.
(7)
. So predicting the outcome of DCM is an important in
its management as revealed by different studies (9, 10, 11). Exclusion criteria: shortness of breath and/or heart
For these reasons, this study had arisen to have a failure due to asthma, congenital heart disease, valvular
baseline data about the natural history of DCM in heart lesion, anemia, active pulmonary tuberculosis,
children in Misan and to determine the characteristic and any other diagnosis other than DCM. In addition,
echocardiographic findings. any case rejected to be involved in this study or did not
complete the follow-up evaluations was excluded.
Patients and Method The study protocol was reviewed; ethical approval
A hospital-based cross sectional study conducted and official permission were obtained from Ministry of
during a period of three years from 2009 to 2012 in Higher Education, College of Medicine in Misan, Misan
Misan province (South East Iraq). directorate of health and Al-Sader Teaching Hospital to
carry out this study. An informed written consent was
The diagnosed cases of DCM were selected from obtained from each patient or from their parents.
the referred patients (54 cases) for an echocardiographic
evaluation in Al-Sader Teaching Hospital with suspicion The analysis of data was carried out using Microsoft
of either DCM or heart failure. A full history, thorough Excel and was presented in form of tables and figures.
clinical examination, Chest x-ray,
electrocardiography, Results
2D-Echocardiography were done for all cases. Finally,
only 44 cases were diagnosed as DCM and included in A total of 44 patients with median age of 11 ± 2.605
the current study. years were diagnosed as DCM. A predominance of male
and negative family history of the same illness was seen
The first echocardiographic evaluation was done at as shown in table 1.
the referral time to confirm diagnosis of DCM followed
by a second detailed echocardiographic evaluation after All patients were symptomatic and the majority was
the patient was stabilized. presented with congestive heart failure at the time of
evaluation as shown in figure 1.
Echocardiographic imaging was performed with
GE machine, model vivid, version E9 following the According to the NYHA classification; the patients
recommendations and the guidelines of American were classified into 4 groups: the majority was from
Society of Echocardiography (12). NYHA 3 reaching 55% followed by NYHA 2 (32%) as
shown in figure 2.
Different electrocardiographic and
echocardiographic characteristics of those patients were Regarding electrocardiographic finding in this
recorded. study; tachyarrhythmia was the commonest. Irregular
rhythm was recorded in a total of 15(34%) patients
According to the New York Heart Association
while atrial fibrillation only was found in 6(13.6%)
(NYHA) classification (13), the patients were classified
patients. On the other hand, all the characteristic
into 4 groups:
findings of echocardiography were shown in table 2.
NYHA 1: angina, dyspnea, syncope, or palpitation
(ADSP) at more than usual physical activity Valvular regurgitation was a common problem. The
majority has mitral and tricuspid valve regurgitations as
shown in table 3.
Table 1: Characteristics of patients with dilated Conted…
cardiomyopathy
Regular 29 (65.9%)
Characteristics Rhythm Number (%)
Irregular 15 (34.1%)
Age in years:
Irregular
1-5 Atrial fibrillation
4 (9.1%) 6 (13.6%)
rhythm
5-12 Bundle branch 40 (90.9%)
Lt.BBB 6 (13.6%)
Mean Age ± SD block (BBB) 11 ± 2.605
Rt.BBB 3 (6.9%)
Gender: Parameter/echocardiographic findings Number (%)
Male 27 (61.4%)
<30% 3 (6.82%)
Female 2D- Ejection 17 (38.6%)
30-40% 15 (34.09%)
Family history of DCM: fraction % >40-50 % 22 (50.0%)
Yes 4 (9.1%)>50 % 4 (9.09%)
No 40 (90.9%)≤ 2.6 0
*Mean LA 2.7-3.1 8 (18.18%)
dimension (cm) 3.2-3.6 32 (72.73%)
3.7- ≥ 4.1 4 (9.09%)
4.0-4.5 3 (6.82%)
*LVID (cm) 4.6-5.0 15 (34.09%)
Mean 5.1-5.5 22 (50.0%)
≥ 5.5 4 (9.09%)
1.35- 1.85 3 (6.82%)
*LVIDs (cm) 1.86-2.1 15(34.09%)
Mean 2.2-2.7 22 (50.0%)
Figure 1: The clinical presentation in patients with 2.8-3.2 4 (9.09%)
DCM
*Normal value (range) for echocardiographic
measurements from reference guidelines (14).

Table 3: Types of valve regurgitations detected

by echocardiography
Valve Number (%)
Mitral 17 (36.36%)
Tricuspid 15 (34.09%)
Combined mitral and aortic 5 (11.36%)
Aortic 1 (2.27%)
Figure 2: Functional classification of heart failure at
the referral time according to NYHA classification Discussion
Table 2: Characteristic findings of electrocardiographic The current study enrolled a total number of 44
and echocardiographic evaluations pediatrics age group patients with median age of 11
±
Parameter/ECG findings Number (%)
2.605 years and male predominance. Those cases were
≤ 100 4 (9.09%)
presented with dyspnea and during clinical evaluation
Heart rate 101-120 14 (31.82%)
aided by other imaging studies were diagnosed as DCM.
(beats/minute) 121-130 21 (47.73%)
≥ 131 5 (11.36%) Different clinical presentations were found but
dyspnea and congestive heart failure were the
commonest
clinical presentation of DCM. Unfortunately, more than cardiomyopathy in two regions of the United
half of congestive heart failure patients were of NYHA States. N Engl J Med. 2003;348(17):1647–55.
class III heart failure (according to NYHA
2. Towbin JA, Lowe AM, Colan SD, Sleeper LA,
classification) (13) in which more morbidity and mortality
Orav EJ, Clunie S, et al. Incidence, causes, and
were found.
outcomes of dilated cardiomyopathy in children.
These findings were against Puggia et al study, in Jama. 2006;296(15):1867–76.
which it revealed that pediatrics DCM had less severity 3. Elliott P, Andersson B, Arbustini E, Bilinska Z,
in comparison with adult, less LBBB, and short duration Cecchi F, Charron P, et al. Classification of the
of heart failure. This may be explained by the late cardiomyopathies: a position statement from the
diagnosis in this study, because most of cases presented
European Society Of Cardiology Working Group
initially with NYHA class III heart failure (15).
on Myocardial and Pericardial Diseases. Eur
Regarding electrocardiographic finding in this Heart J. 2007;29(2):270–6.
study; tachyarrhythmia was the commonest. Irregular 4. Daubeney PE, Nugent AW, Chondros P, Carlin
rhythm was recorded in a total of 15(34%) patients JB, Colan SD, Cheung M, et al. National
while atrial fibrillation only was found in 6(13.6%) Australian Childhood Cardiomyopathy Study.
patients. Arrhythmia was a common cause of death in Clinical features and outcomes of childhood
DCM with heart failure functional Class NYHA class III dilated cardiomyopathy: results from a
and this was compatible with Dimas et al study (16). national population-based study. Circulation.
This study revealed that most cases are of idiopathic 2006;114(24):2671–8.
origin and associated with negative family history of 5. Vishwanathan L, Sridhar M. Preventable cause of
DCM which was in accordance with different studies (15, 17, dilated cardiomyopathy in children. Apollo Med.
18)
. 2011;8(4):315–6.
According to the World Health Organization, DCM 6. Keeling PJ, Gang Y, Smith G, Seo H, Bent SE,
is characterized by dilatation and impaired contraction Murday V, et al. Familial dilated cardiomyopathy
of the left ventricle or both ventricles (19). in the United Kingdom. Heart. 1995;73(5):417–21.

Regarding echocardiography, the present study 7. Nogueira G, Pinto FF, Paixao A, Kaku S.
showed that left atrial size was positively correlated Idiopathic dilated cardiomyopathy in children:
with left ventricular function and the majority had clinical profile and prognostic determinants. Rev
mitral valve regurgitations. Therefore, 2-Dimensional Port Cardiol orgao Of da Soc Port Cardiol Port J
Echocardiography is essential in the diagnosis, as well Cardiol an Off J Port Soc Cardiol. 2000;19(2):191–
as, a good predictor in prognosis. 200.
8. Weng K-P, Lin C-C, Huang S-H, Hsieh K-S.
Conclusion Idiopathic dilated cardiomyopathy in children:
a single medical center’s experience. J Chinese
Dyspnea and heart failure were the most common
Med Assoc. 2005;68(8):368–72.
presenting symptoms in children with dilated
cardiomyopathy. NYHA class III heart failure was 9. Huh J, Noh C Il, Yun YS. The usefulness of
common causing more morbidity and mortality in those surface electrocardiogram as a prognostic
patients. Additionally, imaging studies, especially, predictor in children with idiopathic dilated
the 2-Dimensional Echocardiography was helpful in cardiomyopathy. J Korean Med Sci.
confirming the diagnosis. 2004;19(5):652–5.
Conflict of Interest: No conflict of interest. 10. Azevedo VMP, Albanesi F, Manes F, Santos
MA, Castier MB, Tura BR. How can the
Source of Funding: Not funded. echocardiogram be useful for predicting death in
children with idiopathic dilated cardiomyopathy?
REFERENCES Arq Bras Cardiol. 2004;82(6):505–9.
1. Lipshultz SE, Sleeper LA, Towbin JA, Lowe AM, 11. McMahon CJ, Nagueh SF, Eapen RS, Dreyer WJ,
Orav EJ, Cox GF, et al. The incidence of pediatric Finkelshtyn I, Cao X, et al. Echocardiographic
predictors of adverse clinical events in children cardiomyopathy in children. J Am Heart
with dilated cardiomyopathy: a prospective Assoc.
clinical study. Heart. 2004;90(8):908–15. 2016;5(7):e003450.
12. Hahn RT, Abraham T, Adams MS, Bruce CJ, 16. Dimas VV, Denfield SW, Friedman RA,
Glas KE, Lang RM, et al. Guidelines for Cannon BC, Kim JJ, Smith E, et al. Frequency
performing a comprehensive transesophageal of cardiac death in children with idiopathic
echocardiographic examination: dilated cardiomyopathy. Am J Cardiol.
recommendations from the American Society of 2009;104(11):1574–7.
Echocardiography and the Society of
17. Wettrell G. Dilated cardiomyopathy of unknown
Cardiovascular Anesthesiologists. J Am Soc
cause in young patients: risk evaluation, possible
Echocardiogr. 2013;26(9):921–64.
etiologies, and treatment. Libyan J Med.
13. Levin R, Dolgin M, Fox C, Gorlin R. The Criteria 2007;2(4):157.
Committee of the New York Heart Association:
18. Kindel SJ, Miller EM, Gupta R, Cripe LH, Hinton
Nomenclature and Criteria for Diagnosis of
RB, Spicer RL, et al. Pediatric cardiomyopathy:
Diseases of the Heart and Great Vessels. LWW
importance of genetic and metabolic evaluation. J
Handbooks. 1994;9:344.
Card Fail. 2012;18(5):396–403.
14. Overbeek LIH, Kapusta L, Peer PGM, De Korte
19. Weintraub RG, Nugent AW, Davis A, King
CL, Thijssen JM, Daniels O. New reference
I, Bharucha T, Daubeney PEF. Presentation,
values for echocardiographic dimensions of
echocardiographic findings and long-term
healthy Dutch children. Eur J Echocardiogr.
outcomes in children with familial dilated
2006;7(2):113–21.
cardiomyopathy. Prog Pediatr Cardiol.
15. Puggia I, Merlo M, Barbati G, Rowland TJ, 2011;31(2):119–22.
Stolfo D, Gigli M, et al. Natural history of dilated
DOI Number: 10.5958/0976-5506.2019.01642.5

Effect of Exercise and Body Mass Index (B.M.I.) on Fitness

Khalidah Nayyef Mustafa

Northern Technical University, Technical Institute, Mosul, Nursing Department

ABSTRACT
Background: Both Body Mass Index (B.M.I.) and fitness level are very important factors affecting risk of
many disease or infections such as hypertension especially in obese men(overweight) without any exercise,
therefore aim of current study were study the role of both exercise and Body Mass Index (B.M.I.) on the
Fitness.
Material and Method: This study has been done upon (180) students in Nursing department (70) males,
(110) females, their age ranged between (18-24) years.
Findings: Current study found 55(25 males,30 females ) have high level of fitness with B.M.I.
ranges
between (18 – 30Kg/m2 ) and all them always do physical exercise daily. The study showed 80(35 males,
45 females ) with less fitness depending on time required to return to rest values of vital signs (25) of them
do exercise every day,but (55) don’t do any physical activity. Also the study indicates that (45) of sample
(10 males, 35 females) have low fitness with B.M.I. ranges between (22-30 Kg/m2 ) without any physical
activity.
Conclusion: (50%) of the sample of both sex were practise proper sports and average body mass is (19-26
k.g/s.m) is the best concerning physical activity, the level of physical fitness decreases if body mass
exceeds (26 k.g/m2)and proper sports exercises can lessen the negative impact of overweight on physical
fitness.

Keyword: Exercise; Body Mass Index: (B.M.I.) and Fitness

Introduction people suffering from over-weight, when they run for
one mile and then taking measure criteria (age, length,
Gymnastic or sports exercises make a series of
weight, and body mass) there was an abstract sharp
body self-responses which improve the vascular cardiac
difference between the two groups as pulse average and
system, and play an important role in treating many
blood pressure of each group.4
morbid cases without the use of drugs such as pulse
rates, breathing, blood pressure, muscle strength, and Weak physical fitness among children and
sustaining physical fitness.1 The impact of gymnastic adolescents is an important factor that cause health
exercises by (10) minutes a day for three successive problems in blood vessels later on among middle aged
days is the same as that of the physical fitness when people and develop to other diseases and there is a
practiced by two minutes a day for (15) days or one relation with body mass among normal adolescents and
minute for (30) days and there was a considerable their physical fitness.5
decrease in weight and increase in vital capacity.2
Hypertension is of the health challenges all over the Proper sport practice depending on body building
world, different epidemic studies indicate that that leads and enduring exercises has positive results in that part
to diseases of blood vessels and kidneys and others. of the extra energy leaks the thing that improves muscle
Treating hypertension lessens the risk of the results functions and body systems, practicing bodily exercises
incurred on being infected with these diseases and the for (30) minutes everyday leads to burning sugar
organized gymnastic exercises have played an molecules as hard labour is sufficient to burn the same
amount of sugars.6
important role to treat high blood pressure by the use
of drugs and clinical results confirm the usefulness Sport exercises practicing in fresh air increases the
of practicing sports on the long run.3 When comparing vital capacity which leads to a lot of health benefits,
physical fitness levels between two groups, the first and when using three kinds of labour methods to
consists of ordinary people and the second of
622 Indian Journal of Public Health Research
Indian & Development,
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 622

distinguish benefits, there was an absolute coincidence Material and Method

with laboratory examinations of blood vessels safety
and respiratory system due to the amount of oxygen and The weight and the length of (180) students were
comparing it against the standard volume at rest.7 The measured, (70) of them are males and (110) females,
impact of these exercises on lessening blood pressure their age ranged from (18-24) years. Then the body mass
varies in general, when asking normal women and others was calculated by dividing weight (k.g) by length (cm)
with high blood pressure to practice trunk, legs, knee then measuring the vital signs for each one of them
and dual muscles exercises during three various periods, which are pulse, breathing and blood pressure at
the fall in the systolic pressure was obvious in some of complete rest by using (sphygmomanometer and
these exercises whereas no such thing happened in both stethoscope).
groups while practicing other exercises. 8
After that each individual was exposed to physical
The mass of the body has a negative impact when stress by using the (treadmill) at 7 k.m/h for ten minutes,
exceeding (30k.g/s.m). When comparing the nutritional then directly after the exercise all the vital signs were
state with body mass of a number of university students measured and the time was also measured for the rates to
in Nigeria for a complete year, the laboratory analyses move from a state to state, the criterion used to measure
indicate negative effects as to the various body systems.9 physical fitness was the least time required for the rates
Obesity is one of the increasing health problems in to return to their initial state.
Canada and decreasing it is of the important factors to
specify the relation between physical fitness and the Findings
working of both the vascular and respiratory systems
in the proper manner, and keeping body mass does not When the experiment was conducted on (180)
lead to obesity in the future. 10 When testing the impact students at the Nursing Department (70/38%) males
of body weight on the level of physical fitness of many whose body masses ranged from (17-30 k.g/m 2), and
personnel of the marines in Croatia aged (27) with (110/62%) females whose body masses ranged from
body mass (86.2k.g/m2), there was an adverse relation (17-33 k.g/m2).
between fat rate and three tests connected with physical Table 1: Sample as Gender and Body Mass Index
fitness. In the light of that the weight administration (B.M.I)
programme was allocated to decrease the appropriate
amount on the long run to enable those people to live Gender No. % B.M.I kg/m2
in the environment and the kind of work they practice.11 Male 70 38% (17-30)
Dancing in fresh air has a positive impact on the blood Female 110 62% (17-33)
vessels, when a three-month- dancing programme was Total 180 100%
conducted on many women ranging from twenty years
to twenty-five, there was a positive effect on the systolic Table (1) showed that people who were in rest their
and diastolic blood pressure and the average number of vital signs was within normal range for males (pulse 78/
inhaling and exhaling per minute which allows entering min, respiration rate 19/min, blood pressure 120/80)
a larger amount of oxygen. 12 and for females (pulse 78/min, respiration rate 16/min,
blood pressure120/80) and after exercise there was clear
The aim of study is encouragement people to do increase in all signs for both sex, for males (pulse 120/
continuously exercise to keep normal B.M.I to get min, respiration rate 40/min, blood pressure 140/80)
highest fitness. and for females (pulse 111/min, respiration rate 36/min,
blood pressure 130/80)
Table 2: Average of vital signs before and after exercise

Vital signs during rest Vital signs after exercise

Gender Pulse Beats/ Respiratory rate Blood pressure Pulse Beats/ Respiratory rate Blood pressure
minute Once/minute mm./Hg. minute Once/minute mm./Hg.
Male 78 16 120/80 120 40 140/80
Female 78 19 120/80 111 36 130/80
In this table (2) illustrate the increased the vital signs (Pulse; Respiratory rate, and Blood pressure) after exercise
compared to during rest

Table 3: Sample who having long practise and haven’t

Have practise Don’t have practise
Gender Total
No. % No. %
Male 45 50% 25 27.8% 70
Female 45 50% 65 72.2% 110
Total 90 100% 90 100% 180

Results in table -3 showed that both males and females (No.= 45, 50%) were get good practise for
suitable
period, so females who do not have practise (No.= 65, 72.2%) more than male (No.= 25, 27.8%).

Table 4: Person who have highest physical fitness with good practise
No. B.M.I kg/m2
Gender
18 19 21 22 24.8 25 26 29.5 30
Male 25 ‫ــــ‬ 6 4 ‫ــــ‬ 7 3 5 ‫ــــ‬ ‫ــــ‬
Female 30 8 ‫ــــ‬ 8 5 ‫ــــ‬ 2 ‫ــــ‬ 5 2
Total 55 8 6 12 5 7 5 5 5 2

From the above results, it was seen that the students with the highest physical fitness were those who lasted five
minutes to return to the rest rates and their number was (55)-25males and 30females, with body mass (19-26k.g/m2)
for males, and (18-30) for females and all practise proper sports as is illustrated in table (4).

Table 5: Person who have medial physical fitness

B.M.I kg/m2
Gender No.
17 18 20 22.6 23 24.8 25 25.5 26 27 28
Males have practise 10 ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ 6 ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ 4
Males haven’t practise 25 3 ‫ــــ‬ 7 ‫ــــ‬ ‫ــــ‬ 4 6 5 ‫ــــ‬ ‫ــــ‬ ‫ــــ‬
Females have practise 15 ‫ــــ‬ ‫ــــ‬ 3 ‫ــــ‬ 7 ‫ــــ‬ 5 ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬
Females haven’t practise 30 4 6 10 ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ 5 5 ‫ــــ‬
Total 80 7 6 20 6 7 4 11 5 5 5 4

Table (5) showed that (80) of the sample were have medial physical fitness and they needed (6-7) minutes. Of
them (25) practise regular sports and (55) do not and the body mass of this group were (17-28 k.g/m2).

Table 6: Person who have least physical fitness

B.M.I kg/m2
Gender No.
22 23 26.9 27 28 30
Males have practise 10 3 ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ 7
Males haven’t practise ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬
Females have practise ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬ ‫ــــ‬
Females haven’t practise 35 5 5 3 7 5 10
Total 45 8 5 3 7 5 17
As for the group with the least physical fitness as sports and average body mass is (19-26 k.g/m2) is
in table No.(6), of them were (45) as ( 10 Males and 35 the
Females) where it took them (8-12) minutes to return to
the initial state, most of them were of those who do not
practise proper sports and their body mass were (22-30
k.g/m2).

Discussion

Physical activity is considered one of the important

factors that lead to the loss calories that are not needed
by the body –the surplus- and preventing fat from
concentrating in various body tissues which leads to
increase of endurance and physical fitness. The study
has revealed that the individuals with the highest fitness
are those who practise proper sports exercises everyday,
Of the dependable criteria to measure fitness as in our
study are pulse rates, breathing, blood pressure, and the
time required to return to the rest state and here there is
one of the most important indicators to specify the level
of the physical fitness besides other criteria as oxygen
consumption.13

Using up to date devices such as the (treadmill) to

gauge the labour has an important effect in getting the
results of the students at the preparatory and university
stages. It is of benefit in increasing the capacity to
endure and strengthening muscles especially legs and
trunk muscles and this was emphasised by similar
studies in this regard. 14

Body mass has a noticeable effect on some of the

elements of physical fitness. In our research it is noticed
that those with a certain body mass can continue doing
the exercise using the (treadmill) device longer than the
time determined in the research and did not get tired
on the contrary to those with larger body mass and this
coincides with other studies. 10,15

The study shows that the individuals with the least

fitness do not practise proper sports and their body
masses are larger than normal. Those people with medial
fitness according to the criteria of the research were
practising some physical activities yet improperly. We
believe that physical activity lessens the negative impact
of body mass which is larger than usual and this is
confirmed by other studies. 6

Conclusions

(50%) of the sample of both sex were practise

proper
best concerning physical activity, the level of physical
fitness decreases if body mass exceeds (26 k.g/m2)and
proper sports exercises can lessen the negative impact of
overweight on physical fitness.

Conflict of Interest: Nil

Source of Funding: Self

Ethical Clearance: Not required

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DOI Number: 10.5958/0976-5506.2019.01643.7

Analysis of Related Factors with Anxiety Occurrence in

Population with the Risk of Coronary Heart Disease in
Indonesia

Titin Andri Wihastuti1, Fajaruddin Fajaruddin1, Tina Handayani Nasution1, Kumboyono Kumboyono1,
Yulia Candra Lestari2
1
School of Nursing, Faculty of Medicine, Brawijaya University; 2School of Nursing, Kendedes Institute of
Health Sciences

ABSTRACT
Background: Anxiety is one of the psychological factors as an independent factor of predictors coronary
heart disease (CHD) and proven to play a strong role in increasing the risk of CHD doubling.
Aim: Objective of the study is to identify the relationship of socioeconomic status, type of personality and
coping mechanism with anxiety occurrence in population with the risk of CHD.
Method: The study used analytical observation with cross sectional approach. The respondents were 111
individuals with the risk of coronary heart disease. The sampling method was purposive sampling. The
study was conducted in Malang, Indonesia on April 2018.
Result: Spearman rank correlation test showed a significant relationship between socioeconomic status
(p=0.009), type of personality (p=0.038) and coping mechanism (p=0.000) with anxiety occurrence in
population with the risk of CHD. Logistic regression test showed that coping mechanism is the most
correlation factor with anxiety occurrence in population with CHD risk (OR=5.343) compared with other
factor. It is important to provide skills of coping mechanism for population with the risk of coronary heart
disease.

Keywords: socioeconomic status, personality, coping mechanism, anxiety, coronary heart disease,
risk
Introduction and the number continues to increase with age (highest
group at age 65-74 years). The highest incidence of the
The high prevalence of morbidity and mortality due
majority in women, the population not in school, not
to coronary heart disease (CHD) became a major health
working, urban domicile, and low economic status2.
problem in various countries of the world including
Indonesia. World Health Organization (WHO) data from Epidemiological studies have a clear influence
2012 shows that of 56.5 million deaths worldwide, 31% on the risk of CHD, ie irreversible risk factors such
are due to cardiovascular disease where 42.3% is caused as age, sex, ethnicity, genetics, geography and change
by CHD1. CHD became the highest cause of death at all of life, as well as changeable risk factors such as
ages in Indonesia of 12.9% with a prevalence of hypertension, hypercholesterolemia, diabetes, obesity,
1.5% diet, smoking, exercise, lifestyle, social circumstances
and psychological factors3. Psychological factors
such as stress anxiety and depression are predictor
Corresponding Author: independent factorsand are twice as likely to increase
Kumboyono Kumboyono the risk of developing CHD4. Acute anxiety leads
School of Nursing, Medical Faculty, to hyperventilation resulting in seizures in the heart
Universitas Brawijaya, Indonesia muscle, increased sympathetic nervous system work
Phone: +6281805004106 and triggering episodes of ventricular arrhythmias that
Email: [email protected] affect cardiovascular health and trigger CHD. Anxiety
[email protected] increased neuroendocrine and platelet activation5,6.
627 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 627

Factors that affect anxiety consisting of intrinsic Methodology

factors such as age, experience undergoing treatment
and personality type7. While extrinsic factors are The study used analytical observational design with
cross sectional approach. The respondents were 111
medical condition or disease diagnosis, and access of
individuals with coronary heart disease risk selected
information, adaptation process or coping mechanism, using the purposive sampling method. The study was
socioeconomic status and family disease history. Factors conducted in Kota Lama, a sub-region in
of experience undergoing treatment and diagnosis of Kedungkanandg, Malang City, Indonesia on April 2018.
disease occur in someone who has suffered from CHD. The instrument was questionnaire. Bivariate analysis
While the study of this study is a factor that affects the and spearman rank correlation were used to identify
incidence of anxiety in healthy populations that have relationship between socioeconomic status, type of
personality and coping mechanism with anxiety in
risk factors for CHD such as age, sex, family heart
population with coronary heart disease risk, while
disease history, knowledge, socioeconomic status, type multivariate analysis and logistic regression test were
of personality and coping mechanism. used to identify the most significant factor.

Findings

Table 1: General Characteristics of Respondents by Age

N Mean Minimum Maximum Standard Deviation (SD)
Age (year) 111 52.36 27 78 11.722
Source: Primary Data (2018)
Table 1 showed that the average age of respondents Conted…
is 52.36 years with a standard deviation of 11,722. The
youngest age of 27 years and the oldest age of 78 years. Not Anxious 38.7
Total 100
Source: Primary Data (2018)
Table 2: Distribution of Respondent Characteristics
and Variable Table 2 showed that from 111 respondents, most
with moderate socioeconomic status (41.9%), most with
Characteristics % type B personality (39.1%), almost half with less coping
Socioeconomic status mechanism (43.7%), and most experienced anxiety is 68
Low 28.8 people (61.3%).
Medium 36.9
High 34.2 Table 3: Spearman Rank Correlation Test Results
Total 100 Between Socioeconomic Status, Type of Personality
Type of Personality and Coping Mechanism with Anxiety Occurrence in
Type A 18.0 Population with The Risk of CHD
Type B 35.1
Type C 27.9 Variable
Type D 18.9 Socioeconomic Status
Total 100 Type of Personality
Coping Mechanism Coping Mechanism
Poor 38.7
Good 61.3 Source: Primary Data (2018)
Total 100 Table 3 shows the p value < α (0.05) meaning that
Anxiety there is a significant relationship between socioeconomic
Anxious 61.3 status, type of personality and coping mechanisms with
anxiety occurrence in population with the risk of changes in cardiovascular function, increase the
CHD risk of CHD. A person with a job status and a
in Malang. fixed income will feel more peaceful life because
the problems of daily living and economic needs
Table 4: Logistic Regression Test Results can be met so as to reduce the burden of thoughts
Factors Most Associated with Anxiety and psychological pressure that can cause
Occurrences in Populations with The Risk of anxiety12,13.
CHD 2. Relationship between Type of personality and
Variabel P Value Exp (B) R Square Anxiety Occurrence in Population with The
Type of Personality 0.032 0.560 Risk of Coronary Heart Disease: The bivariate
0.430 analysis showed that there was significant
Coping Mechanism 0.006 5.343
relationship between type of personality and
Socioeconomic Status 0.966 0.983
anxiety in population with the risk of coronary
Source: Primary Data (2018) heart disease, since the p value < α (0.05) and the
correlation score was negative. It indicated that
Based on table 4 it is known that R Square 0.430,
type of personality was inversely proportional to
meaning 43% of anxiety occurrence in population
anxiety incidents, in which an individual with type
with high risk of CHD can be explained by factors
A personality was more prone to anxiety compared
socioeconomic status, personality type and coping
to individuals who have other types of personality.
mechanism.
Type A personality is associated with anxiety
Discussion and increases the risk of CHD14. This type of
personality feels more anxious and has a negative
1. Relationship between Socioeconomic Status
coping style that increases the risk of CHD 15,16.
and Anxiety Occurrence in Population with
This is reinforced by the results of studies that
The Risk of Coronary Heart Disease: The
show that the hostile component of Type A
bivariate analysis showed that socioeconomic
personality is the most significant risk factor for
status correlated significantly with the occurrence
stress and anxiety17.
of anxiety in population with risk of CHD, since
the p value < α (0.05) and the correlation score The development of the concept of stress,
was positive. This indicates that the lower the psychodynamics and psychosomatic disorders,
socio-economic status of a person, the more likely personality type is used to be an important idea in
to experience anxiety. The results of this study which personality type A is associated with stress
are consistent with several research results which and anxiety and promotes the development of
show that low socioeconomic status and financial coronary heart disease18. In addition, personality
pressures felt to be significantly related to anxiety. type D is also described as a personality that
Individuals with good socioeconomic status can connects with negative affective and emotional,
protect emotional stress and anxiety 8,9,10.Low avoidive coping styles and social inhibitions
socio-economic status will cause individuals to associated with cardiovascular disease and the
experience anxiety more easily, this is evidenced development of CHD risk19.
by the results of studies that show the prevalence
of anxiety decreases with higher socioeconomic 3. Relationship between Coping Mechanism
status and Anxiety Occurrence in Population with
prevalent. in The
7,11
peopleprevalence of diseaseclass.
with low socioeconomic is
The Risk of Coronary Heart Disease: The
more
In this study also found most respondents who bivariate analysis showed that coping mechanism
experience anxiety in those who do not work, as correlated significantly with the
housewives, do not have a permanent job and with occurrence
of anxiety in population with risk of
types of jobs such as car drivers, sellers, factory CHD,
since the p value < α (0.05) and the
workers and traders. Anxiety is more common correlation
score was positive. This means that the less
in societies with lower socioeconomic status the
ability of coping mechanism, the tendency to
and then results in acute or chronic physiologic experience anxiety is higher. The results of
this
study are in line with research that shows that Conclusion
low coping mechanism during adolescence are
associated with an increased risk of heart disease There is a significant correlation between
during adulthood20. Individuals with low coping asocioeconomic status, personality type and coping
mechanism ability when faced with difficulties, mechanism with anxiety occurrence in population with
will be more susceptible to stress that can cause risk of CHD. Coping mechanism is the factor most
anxiety, depression, anger, impulsiveness and low associated with anxiety events in the population with
self esteem. CHD risk compared with other factors. It is important to
provide skills of coping mechanism for population with
Coping mechanisms can regulate negative and the risk of coronary heart disease.
positive emotions as well as improve self-efficacy
in stress relief so that individuals can reduce or Ethical Clearance: Ethical, Health, and Research
eliminate anxiety. Whenever there is a stressor, Commission of the Medical Faculty, Brawijaya
the individual automatically appears to attempt University (number: 216/EC/KEPK/06/2017).
to cope with various coping mechanisms21. The
Source o Funding: Self
use of coping mechanisms will be effective
when supported by individual beliefs against Conflict of Interest: Nil
the coping used can reduce or eliminate anxiety.
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DOI Number: 10.5958/0976-5506.2019.01644.9

What are the Staffing Levels and Maternal Outcomes? A

Descriptive Study in Referral Hospitals in Java, Indonesia

Makhfudli Makhfudli1, Ferry Efendi1, Anna Kurniati2, Retnayu Pradanie1, Susy Katikana Sebayang3
1
Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia; 2Center for Planning and Management
of Human Resources for Health, BPPSDMK, Ministry of Health, Indonesia; 3Faculty of Public Health,
Universitas Airlangga, Banyuwangi Campus, Indonesia

ABSTRACT
Adequate maternity staffs (obstetric/gynecologists, midwives, and nurses) at referral hospitals are crucial to
manage obstetric complications and to improve maternal outcomes. This study aims to describe the staffing
levels and maternal outcomes in selected referral public hospitals in Java region of Indonesia. The data of
8,396 deliveries with live birth and 522 maternity staffs were collected from six referral hospitals in Java,
Indonesia. Descriptive statistics were employed to summarize the study subjects. The maternity staffing
levels of the study hospitals were relatively sufficient, however, the maternal mortality ratio and the severe
maternal outcome ratio are moderately high. Further studies are recommended to understand the effect of
staffing and other possible factors on maternal outcome.

Keywords: maternal, midwife, nurse, referral hospital

Introduction 305 per 100,000 live births in 2015.4 This achievement
is in line with the increase proportion of skilled birth
Maternal mortality is the second highest cause of
attendance. By 2015, the percentage of skilled birth
death among women of reproductive age with nearly
attendance has exceeded the national target at 93.1%.5
eight hundreds women died every day from maternal
However, approximately 20.5% of births are
causes.1 In addition maternal morbidity is experienced delivered
by approximately twenty million women around the at home.5
world that leads to death and disability without
prevention or appropriate treatment.2 Considering the Skilled birth attendance at health care facilities
magnitude of this issue, improving maternal health is a key strategy in Indonesia to prevent delays in
continuously receive a major concern from the global managing obstetric emergencies. Based on the 2012
stakeholder. The Sustainable Development Goals set a Indonesian Demographic and Health Survey, more than
target to reduce the maternal mortality ratio by 70 deaths 80% of maternal deaths occur in hospitals. It indicates
6

per 100,000 live births by 2030.3 that women with obstetric complications may not
arrive timely at the hospital or may receive inadequate
Despite the declining trend of maternal mortality treatment while in the hospitals. The Government
ratio (MMR), Indonesia is among other developing of Indonesia stated that delays in making decision
countries with a high number of maternal deaths. Based to seek care, making referral to health facilities, and
on the national population census reports, the MMR has managing obstetric emergency care due to constraints
been reduced from 390 per 100,000 live births in 1991 in infrastructure and human resources are among
to contributing factors to maternal mortality.7

Health workforce is a central component within the

Corresponding Author: health system. To improve maternal health, appropriate
Ferry Efendi, SKep.Ns, MSc, PhD staffing has been strongly recommended by policy makers
Faculty of Nursing, Universitas Airlangga, from international and national institutions. This policy
Surabaya, Indonesia is partly supported by evidence, as various studies have
Email: [email protected] reported the significant relationship between higher
staffing
632 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 632

and positive health outcome.8 A previous review study 1. Death: women who died in the hospital from
reported that shortage of health workers and imbalance maternal causes
distribution occur in various public health facilities in
2. Near-miss: women who almost died from
Indonesia.9 This study, therefore, aims to describe the
maternal conditions within 42 days after the
staffing levels and maternal outcomes in several referral
pregnancy terminated
public hospitals in Java region of Indonesia.
3. Survive: women who are alive at the time of
Method discharge from hospital.

Study Design, Setting, and Sampling: This study Other variables represented the characteristics of
employed an observational study design using the obstetric patients include:
retrospective data from the hospital administrative 1. Age
electronic database. The hospital study location was
purposively selected based on the similarity of structural 2. Place of residence:
characteristics of the hospitals. Data of obstetric patients z Same city : the patients were residents of the
and maternity staffs were collected from six referral city where the hospital located.
hospitals with eleven maternity wards within Java
region, Indonesia from September to December 2017. z Other city: the patients were residents of
The study employed the total sampling technique to other cities.
capture data of all study subjects. We included all 3. Admission procedure: referral and non referral.
deliveries with live birth (single and multiple births).
Stillbirth and incomplete data of deliveries were 4. Payment scheme: insurance and out of pocket.
excluded from the data analysis. 5. Types of delivery: vaginal spontaneous delivery,
instrumental delivery, caesarean section, and
Study Variables: Nursing staffs included registered
other assisted delivery.
nurses and diploma nurses, while midwifery staffs
consisted of professional midwives and diploma 6. Types of live birth: single and multiple
midwives. Variables of staffing levels will be presented 7. Length of stay: days of hospitalization calculated
as an aggregate at the maternity unit level, including:
from the day of admission to the day of discharge.
1. Nurse to patient: number of nursing staffs per
8. Type of maternal complications underlying causes
1000 patient/year.
of morbidity and mortality.
2. Midwife to patient: number of midwifery
staffs Data Analysis
per 1000 patient/year.
Descriptive statistics method was employed
3. Maternity staffs to patient: number of nursing and
midwifery staffs per 1000 patient/year. to analyze the data to generate the study results in
forms of frequencies, percentages, mean, ranges, and
4. Proportion of nurses and midwives with bachelor standard deviation. This method allowed to summarize
degree. the characteristics of the study subjects based on the
5. Average years of nursing experience. variables selected.

6. Average years of midwifery experience.

Results
7. Proportion of permanent staffs.
The data of 8,396 patients with live birth deliveries
One variable of the staffing level of obstetrician/ and 522 maternity staffs (medicine, nursing, and
gynecologist (ob/gyn) is presented in ratio per 1000 midwifery staffs) were obtained from six hospitals. Table
patient/year at the hospital level. 1 displays the statistics summary of variables of staffing
Variables of maternal outcomes represented the levels. The mean nursing staffing level at maternity unit
outcome of obstetric patients that are categorized as was 26.1 nurses per 1000 patient in a year. The
follows: average
midwifery staffing level at maternity unit was 21.8 of experience between nursing staffs and midwifery staffs
midwives per 1000 patient per year. The maternity staffs per maternity unit were quite similar at 11.1 years
showed an average ratio of 47.9 staffs to 1000 patient and
per year. The proportion of nurses and midwives holding 11.3 years respectively. The mean of the proportion of
bachelor degree in maternity units was ranging from permanent staffs at the maternity unit was 74.3%. At the
2.0% to 57.4%, with 25.0% at the average. The hospital level, the mean of the staffing level of ob/gyn
average years was
13.6 ob/gyn per 1000 patient in a year.

Table 1: Descriptive statistics of staffing levels by maternity unit

n = 11
Staffing levels Minimum Maximum Mean SD
Nurses to patient 5.0 45.4 26.1 15.09
Midwives to patient 7.1 50.7 21.8 12.24
Maternity staffs to patient 27.8 66.2 47.9 15.32
Proportion of nurses and midwives with bachelor degree 2.0 57.4 25.0 18.74
Average years of nursing experience 2.7 21.6 11.1 5.74
Average years of midwifery experience 6.7 26.0 11.3 5.23
Proportion of permanent staffs 34.9 100.0 74.3 22.42
Ob/gyn to patient*) 6.1 29.9 13.6 8.86
*) calculated at hospital level
Table 2 presents the characteristics of obstetric Conted…
patients included in this study. The mean age of the
study subjects was 29.8 years old. Most of patients Types of delivery
(67.1%) were residents of the city where the hospital Vaginal spontaneus 3,088 (36.8)
located. Admission to the hospital were mostly through Instrumental 471 (5.6)
medical referrals (74.5%). Insurance was the most
Caesarean section 4,837 (57.6)
payment scheme utilized by the patients (84.7%).
Surprisingly, although most deliveries were single live Type of live birth
birth (98.5%), more than half deliveries were conducted Single 8,266 (98.5)
through Caesarean section. Majority of patients (83.9%) Multiple 130 (1.5)
were reported to have maternal complications. The mean Complications
length of stay in the hospital was 4.2 days. While most No 1,354 (16.1)
maternal outcomes (97.2) were positive, 15 patients died
Yes 7,042 (83.9)
and 221 patients experienced near-miss events.
Length of stay - 4.2 ± 2.93
Table 2: Characteristics of obstetric patients Patient outcome
N = 8,396 Death 15 (0.2)
Variables Number (%) Mean ± SD Near-miss 221 (2.6)
Age - 29.8 ± 6.52 Survive 8,160 (97.2)
Place of residence Table 3 shows the outcome of patients who
Same city 5,632 (67.1) experienced maternal complications (n=7,051). Most
Other city 2,764 (32.9) of the underlying causes of maternal mortality and
Admission procedure near-misses were complications predominantly related
Self-referral 2,138 (25.5) to puerperium and other conditions at 40% and 24.4%
Medical referral 6,258 (74.5) respectively. Overall, maternal complications were
Payment scheme dominated by conditions specified in the group of other
Out of pocket 1,288 (15.3) maternal care related to fetus and amniotic cavity and
Insurance 7,108 (84.7) delivery problems (36.4%).
Table 3: Types of maternal complications by patient outcome n = 7,051
Patient outcome, N (%)
Maternal complications
Death Near-misses live Total
Oedema, proteinuria, and hypertensive disorder 1 (6.7) 44 (19.9) 1,454 (21.3) 1,499 (21.3)
Placenta praevia, premature separation of placenta
1 (6.7) 26 (11.8) 231 (3.4) 258 (3.7)
and antepartum haemorrhage
Other maternal care related to fetus and amniotic
2 (13.3) 53 (24.0) 2515 (36.9) 2570 (36.4)
cavity and possible delivery problems
Obstructed Labour 0 (0.0) 4 (1.8) 188 (2.8) 192 (2.7)
Postpartum haemorrhage 0 (0.0) 3 (1.4) 30 (0.4) 33 (0.5)
Other complications of pregnancy and delivery 5 (33.3) 29 (13.1) 1582 (23.2) 1616 (22.9)
Complication predominantly related to puerperium
6 (40.0) 54 (24.4) 666 (9.8) 726 (10.3)
and other conditions
Other not specified complications but may affect the
0 (0.0) 8 (3.6) 149 (2.2) 157 (2.2)
maternal outcome.
TOTAL 15 221 6,815 7,051

Discussion the suggested staffing levels in maternity inpatient units

were one midwife or nurse for every five patients on a
Our study showed that the mean of staffing levels
day shift and for every eight patients on the evening
of nurses is slightly higher than the staffing levels of
shift.13
midwives. The minimum ratio and the maximum ratio
have a wide range in both nursing and midwifery In this study, the mean of the proportion of staffs
staffing levels, but narrower range in the maternity with bachelor degree in maternity units was 25%, while
staffing level at 47.9 staffs per 1000 patients a year. both the mean years of nursing experience and
This finding implies that nursing and midwifery staffs midwifery experience were quite similar at
in maternity units may have substitution roles. The approximately eleven years. Previous studies reported
availability of ob/ gyn in referral hospitals is crucial. In the significant factors of staffs educational background
our study, there was a wide range of ob/gyn staffing and the duration of staff experience to the improved
level among the study hospitals from 6.1 to 29.9 ob/gyn patient outcome.14 A previous study reported that the
per 1000 patients per year, with an average of 13.6 likelihood of patients dying was 30% lower in the
ob/gyn per 1000 patients a year. A previous study in hospitals with 60% of staffs with bachelor degree in
England, reported that the mean for each maternity nursing than in hospitals with only 30% of nursing staffs
staffing levels was 29.6 midwives, with bachelor degree.15
1.4 consultant ob/gyns, and 4.3 junior ob/gyns per 1000
The average age of obstetric patients in this study
deliveries a year.10
was 29.8 years old, insurance users, and mostly admitted
In Indonesia, the staffing in the maternity unit is through the referral procedure. Most of patients were
determined based on the hospital classification. Referral having maternal complications which may indicate
hospitals of type A and type B are recommended to have the reason for accessing the referral level of care.
the staffing ratio of one nurse or midwife per patient.11 This finding is not surprising, considering the data of
This regulation implies that at the secondary or tertiary this study was taken from the 2016 hospital database
referral level of care every patient should be attended by which was the second year of the implementation of
either a nurse or a midwife at all shifts. Other countries the National Health Insurance system. The system may
such as the United Kingdom and Australia also had have contributed to the increasing access of women with
different recommendation related to the optimum maternal complications to referral health facility.
maternity staffing. The UK suggested 36 midwives Our study showed that the maternal mortality ratio
per was 178.8 per 100,000 live births. According the World
1000 births to manage one to one care throughout Health Organization (WHO), the MMR is categorized
the as moderately high if the range falls between 100 to 299
childbirth process and other period of care.12 In Australia,
maternal deaths per 100 000 live births. The MMR in REFERENCES
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and Higher Education of Indonesia number 004/ADD/ birth. Journal of Obstetrics and Gynaecology.
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levels and the incidence of mortality and
morbidity
DOI Number: 10.5958/0976-5506.2019.01645.0

Estimation of Procollagen Type III Peptide (PIIIP) Level in

β Thalassemia Patients

Maryam Kadhim Al-Shemery1, Arshad Noori Al-Dujaili2

1
Physiology and Hematology, Collage of medical Techniques, The Islamic University, Iraq,
2
Biology Department, University of Kufa, Iraq

ABSTRACT
Procollagen type III peptide (PIIIP) is established as biochemical markers of liver fibrosis. So that, type
III (Pro-C3) can be used as diagnostic tools for liver fibrosis. Collagen type III amino-terminal pro-peptide
(PIIINP) is a degradation product of collagen type III, the increase of which may reflect an ongoing fibrotic
process. Procollagen type III is found abundantly in skeletal muscle and other soft tissues such as skin,
and in negligible amounts in bone. During the late phases of collagen synthesis, the N-terminal end of
procollagen type III is cleaved releasing P3NP into the circulation.According to case-control study. This
study was conducted with eighty-eight of males that age ranges from 2-29 years, which divided in 60 of
males with β-thalassemia whom have visited the Thalassemia Center at Al-Zahraa Teaching Hospital in
Al– Najaf province, Iraq, for managed of the disease, and 28 voluntary healthy as a control groups of. The
study was carried out from January 2018 to July 2018., Procollagen type III in β-thalassemic patients and
healthy groups of males. It also investigates the relationship between these biomarkers levels was
measurement by using a solid phase enzyme-linked immunosorbent assay (ELISA) and also, determined
Hb, Body Mass Index, splenic status liver function test (ALT, ASTand ALP).

Keywords: Procollagen type III, ALT, ASTand ALP, β-

thalassemia.
Introduction peptide of procollagen type III (PIIINP) is detached
from procollagen type III, so the fibrogenesis results
Type III collagen contains multiple charged residues
in release of ECM fragments into the blood. Hence the
in the Xaa and Yaa positions of its chain. Type III
quantity of propeptide of procollagen type III can be a
collagen is the second most abundant collagen in human
direct indicator of collagen synthesis and its deposition
tissues after type I and is primarily found in tissues
in the extracellular space (11.12,13). The increased amount
exhibiting elastic properties, such as skin, blood vessels,
of propeptide of type III procollagen may indicate the
and internal organs. Type III collagen is common in fast
transformation of normal liver tissue into connective
growing tissue, particularly at the early stages of wound
tissue. N-terminal propeptide of procollagen type III
repair (1,2,3,4)
(PIIINP) is generated during the synthesis of type III
The amino-terminal propeptide of type III collagen. PIIINP can be measured in the serum as an
procollagen (PIIINP) is an extension peptide of indicator of liver fibrosis and cirrhosis (14,15,16).
procollagen type III, which is cleaved off during
conversion from type III procollagen to type III Material and Method
collagen. PIIINP reflects myocardial fibrosis, which is
higher in the tissue of dilated and dysfunctional left This study was conducted with eighty-eight of
ventricles (6, males that age ranges from 2-29 years, which divided in
7
). Recently, a new ELISA kit was developed by 60 of males with β-thalassemia whom have visited the
applying monoclonal antibody targeting the N-protease Thalassemia Center at Al-Zahraa Teaching Hospital in
cleavage site of collagen type III pro peptide, which
Al–Najaf province, Iraq, for managed of the disease, and
could assess the true synthesis of collagen type III (8,9,10).
28 voluntary healthy as a control groups of. The
In the liver type III collagen mainly occurs study
during was carried out from January 2018 to July 2018.
the synthesis of type III collagen, the N-terminal
pro
638 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 638

Collection of Blood Sample: The Blood samples were

drawn from vein by sterilized synergies with 5
milliliters. The sample put in the two labeled tubes,
first group of tubes contain EDTA as anti-coagulants to
prevent clotting of blood to be used for physiological
studies. The second group of tubes was without anti-
coagulant as gel tubes, for blood to be used for preparing
serum for following biochemical and biomarkers.

Hemoglobin Estimation: The hematological

parameters were performed on EDTA blood using
Mythic 18 (RINGELSAN CO., Turkey) in Hematology Figure 1: Procollagen type III (ng/ml) level in male
Laboratory of Al- Zahraa Teaching Hospital. This patients with β-Thalassemia and control groups
device is a completely automated hematology analyzer. Procollagen type III level in both patient groups as
Biochemical Parameters shown in figure (2). The results indicate the presence of
a significant (P<0.05) increase in mean Procollagen type
Measurements of ALP concentration: This was done III level in serum of β-thalassemia intermedia
by a method based on enzymatic colorimetric test, (11.09 ±
executed with specific kit for test, supplied by 0.94) ng/ml, in comparison with that of β-
BIOLABO. thalassemia
major (8.40 ± 0.72) ng/ml.
Measurements of AST, ALT, ALP concentration:
This was done by a method based on enzymatic
colorimetric test, executed with specific kit for test,
supplied by BIOLABO.

Biomarker Parameters

Estimation Human Procollagen type III ELSA kit:

Specific kit for measuring human IL-1β concentrations
in serum was supplied by Elabscience Biotechnology

Statistical Analysis
Figure 2: Procollagen type III level (ng/ml) in male
The data was statistically analyzed through SPSS
patients with major and intermedia β-thalassemia
package (SPSS, Version 23). The descriptive analyses
between the patients and control groups of Means and Mean serum Procollagen type III level values in
Standard Error. All of these statistically analyzed at the studied of the age groups as shown in figure (3).
significant(P<0.05). The results demonstrated the presence of a significant
(P<0.05) increase in serum Procollagen type III level of
Results male patients with β-thalassemia of the age group (2-10)
year about (10.40 ± 0.84) ng/ml in comparison with the
Procollagen type III level in male β-thalassemia
age group (11-19) about (7.63 ± 1.01) ng/ml.
patient and healthy groups are plotted in figure (1). The
results are finding a significant (P<0.05) increase in Moreover, it presented the same significant increase
Procollagen type III level in β-thalassemia patient group when it was compared of the age group (20-29) about
(9.39 ± 0.59) ng/ml than healthy group (4.49 ± 0.22) ng/ml. (10.74 ± 1.12) ng/ml, with the (11-19) age group about
(7.63 ± 1.01) ng/ml.
639 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 639
c
u compared with healthy Rahim, (2017)
s control group this revealed that the increased
s acceptable with the serum liver parameters
i results of Salama et al., may be caused by iron
o (2015) and Abdulla, storage in the liver which
n (2018). ( )
22,23 is regarded as a notable
victim of iron
In the present study, Many Study of deposition.(32)
the liver function test observed that increased
table revealed a levels of AST and ALT in The results of this
significant increase in the β-thalassemia are due to study have revealed a
Figure 3: Procollagen levels of (p<0.05) in iron overload, a very low increase in serum PCIII
type III level (ng/ml) serum levels of ALP, hemoglobin level with level in male patients with
in male patients of β- AST and ALT. Current very high (AST, ALT) β-thalassemia that
thalassemia according results agree with Zayed, level along with compared to the healthy
to age (2018) who suggested that spleenomegaly is male groups.These results
thalassaemia may be suggestive of poor agree with Wang et al.,
The statistical (2017), which proved that
causes lesions in liver prognosis in these
analysis showed in figure the elevated of serum
tissues indicated by patients. (24,25,26).
revealed to no significant PIIINP levels is a
elevation of serum liver
differences in serum Data in the present potentially sensitive
function criteria levels
procollagen type III level study revealed marked method to predict the risks
(17,18,19).
between both groups significant elevation in for iron overload-related
splenectomized (7.86 ± ALP value increases ALT and AST activities liver fibrosis in Chinese
0.91) ng/ml and in bone turnover and has as well as total and direct thalassemia patients.(32)
unsplenectomized group been reported to be bilirubin levels in
(10.33 ± 0.75) ng/ ml, of regarded as a marker of thalassemia patients Iron overload, that
male patients with β- bone formation (20). compared to controls. take place in a significant
thalassemia. Previous study found that Similar results were proportion of thalassemia
serum ALP is a sensitive obtained by Mansi and patients because of
screening tool for the Aburjai, (2008) and Attia elevate in gastrointestinal
diagnosis of osteomalacia et al., (2012). (27,28) iron absorption (33) and/or
(21). repeated transfusions, (34)
Elevated reflects iron deposition
The same table transaminasaemia in â- in the liver, heart and
showed highly thalassemic children is endocrine glands, and
significance in AST indicative of liver cases cardiac failure,
and ALT levels in male dysfunction and leakage of endocrine disorder and
patients with β- liver metabolites into the liver fibrosis (35).
thalassemia plasma (29). Previous study Transfused iron is
suggested that The iron accumulated first in the
Figure 4:
deposition may cause reticuloendothelial cell
Procollagen type
damage of hepatocyte prior to parenchymal iron
III level (ng/ml)
in splenectomized (ALT & AST elevation) loading in the liver and
and and cholestasis (bilirubin heart (36).
unsplenectomize & ALP elevation), liver
Injury may be as necrosis Study of Knovich et
d of male patients
with β- of hea- ptocellular, al., (2009) proposed that
thalassemia cholestatic disease or liver cirrhosis related to
mixed between these two high serum ferritin levels.
diseases like Although ferritin best
D
granulomatous hepatitis reflects bodyiron store, it
i
s (30,31). is an acute phase reactant
640 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 640
that readily fluctuates
with active infection or
inflammation.(37)
Recent study has been showed liver iron deposition 5. Boudko S P, Engel J, Okuyama, K., Mizuno, K.,
can cause lipid peroxidation, that compromises the Bächinger, H. P., & Schumacher, M. A. Crystal
organelle integrity, thereby partispating to hepatocyte structure of human type III collagen Gly991–
necrosis and apoptosis, and finally causes liver Gly1032 cystine knot-containing peptide shows
fibrogenesis. Iron can also have assisted the hepatic both 7/2 and 10/3 triple helical symmetries.
stellate cells differentiation into collagen producing Journal of Biological Chemistry. 2008;
myofibroblasts(38) 283(47),
32580-32589.
In several studies, it has been shown that PIIINP
6. Zannad, F., Alla, F., Dousset, B., Perez, A., &
can be diagnosed in the serum as an indicator of liver
Pitt, B. Limitation of excessive extracellular
cirrhosis and fibrosis (39). So that, studies based on
matrix turnover may contribute to survival
PIIINP as a liver damage indicator suggest that tissues
benefit of spironolactone therapy in patients with
with high fibro genic activity or non-mature fibrotic
congestive heart failure: insights from the
tissue composed communally from type III collagen. Randomized Aldactone Evaluation Study
These findings raise an intriguing possibility that liver (RALES). Circulation. 2000; 102(22), 2700-2706.
iron overload and liver function are likely correlated
with serum markers of liver fibrosis. Eventually, ferritin 7. Poulsen, S. H., Høst, N. B., Jensen, S. E., &
concentration and liver iron level were significantly Egstrup, K. Relationship between serum amino-
terminal propeptide of type III procollagen and
correlated with liver dysfunction meatured by AST and
changes of left ventricular function after acute
ALT (33).
myocardial infarction. Circulation. 2000; 101(13),
Conflict of Interest: There was no any conflict of 1527-1532.
interest in this study 8. Nielsen, M. J., Nedergaard, A. F., Sun, S., Veidal,
S. S., Larsen, L., Zheng, Q., ... & Leeming, D.
Source of Funding: There was no fund in this study
J. The neo-epitope specific PRO-C3 ELISA
Ethical Clearance: Ethical was According to the measures true formation of type III collagen
Declaration of Helsinki issued by the World Medical associated with liver and muscle parameters.
Association, formulated in experimental protocols and American journal of translational research. 2013;
independent (ethics committees approval university of 5(3), 303.
kufa/college of Medicine 9. Bode, MK, Soini Y, Melkko J, Satta J, Risteli L,
& Risteli J. Increased amount of type III pN-
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DOI Number: 10.5958/0976-5506.2019.01646.2

Study Prevalence of Breast Cancer and the Relation it’s with

Some Risk Factors and Blood Group in Al-Najaf Governorate,
Iraq

Maysoon K.A. AL-Hadrawi1, Noor Ibrahim2, Esaam Mohmmed Turky3, Noor Ismeal Nasser3, Ali k. Meetab4
1
Asisst. Prof., 2Asisst Lecturer, 3Lecturer, Technical institute, Kufa; 4Technical Institute,
Kufa

ABSTRACT
The current study was designed to determine the prevalence of breast cancer compared to other types of
cancer patients who are admitted to the cancer tumors Center/Al Sadr Teaching Hospital in Najaf, For the
period from February to Jun2017. The rate of breast cancer was 21.2 % (215) of the total number of infected
people cancer (1015). this study showed the relation between the type of blood and the prevalence of
infection, where the results were (36.3, 32.1, 22.3, 9.3%) by dependent the factions of blood (A, O, B,AB)
respectively. The incidence of infection in women who use oral contraceptives was (52.7) compared to those
who did not use the pills (5.4). Obesity is also an important factor In the prevalence of infection, where
the proportion of women in obese women (64.5) compared to non-obese (16.1). The study also showed that
there was a relationship between the level of education and the prevalence of breast cancer, which was the
highest rate of infection in uneducated women followed by the holders of primary, preparatory, diploma and
the lowest percentage of the bachelor’s degree, where the percentages were (36.3,28.8,15.8,11.6,7.4) %
respectively.

Keywords: cancer, contraceptives, blood group,

Obesity
Introduction Type of breast cancer is a solid carcinoma and
diagnosed by clinical and postoperative classification It
The growth of normal cell usually results from a
was very important to detect early breast cancer because
tight balance between growth stop signals and growth
the patient’s survival rate for at least five years from the
stimulation signals. Reproduction happens only when
diagnosis of the disease decreases with the development
the cells number is increased. The balance is shifted
to stimulate growth. This occurs during normal tissue of the disease
change and during wound healing. Cells differentiate Most disease injured of human-associated with
during this process and the reproduction stops. When
blood group, ABO blood groups are antigenic,
needed. While in tumor cells there is a defect in this
polymorphic, found on the erythrocyte surface and some
balance, which leads to the continued proliferation of
tissue or other cells.ABO discovered by Landsteiner
cells and loss of differentiation.
in “1900”. In 2015 find the blood types system are
Cancer result from a genetic defect in the body cells important in transfusion medicine. the blood groups are
that transforms it into cancerous cells that are out of allied with many of diseases including vascular disease,
control. They divide and grow at the wrong place and diabetes type 2. so that the study objective to know the
time, leading to the formation of tumors. In initiation relationship between cancer and blood group also study
phase of cancer occur mutation in DNA copy during effect some risk factors on the prevalence of disease.
the division of the cell. This mutation happens with
effect many factors such as viruses infection, radiation, Materials and Procedure
environmental factors, and smoking. when the mutation
causes many mutations, the cell becomes more able to Samples: Blood samples collection from women
life and resistance of immune factors. after that, cancer infected by breast cancer by finger prick method for
speared to other tissues. diagnosis type of blood.
644 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Diagnosis Type of Blood: Diagnosis of blood group Also the results showed that women taking oral
directly by used blood group kit. contraceptives are more likely to be infected( figure
3), and this is agree with Nygren et al. This explains
that the treatment of (estrogen, progesterone) of the
Result and Discussion
risk of breast cancer by 55-100%, Estrogen plays an
Shows the percentage of breast cancer relative to the important role through its receptors in a process Growth
total number of the sample studied and proliferation of cells in the natural breast tissue,
thus increasing the levels of estrogen with a view to
pharmacological treatment May lead to the emergence
of growth and proliferation of cells from control and the
development of cancer

Figure 1: Explain the number patient of infection by

breast cancer for a total number of cancer patients

The results showed that the rate of breast cancer

reached about 21.2% (215) of the total number of cancer
patients(1015) and this indicates the high incidence of
Figure 3: Explain the relation between oral
breast cancer. A blood sample was drawn for each group
contraceptive and breast cancer
of patients with cancer for the purpose of determining
We see a rise in the obesity factor in women with
the blood type, the result explained the women with
breast cancer compared to healthy women (figure 4)
blood type (A) have the highest incidence of breast Consequently, obese females are more likely to develop
cancer, followed by the type of blood (O, B) and the breast cancer, and this is agree with This is because
lowest type of blood (AB) (36.3, 32.1, 22.3, 9.3) % lipid tissue is an important source of estrogen in obese,
respectively. These results are agree with the results as fat cells increase the of fat number Sex hormones in
of a number of studies that attempted to prove the the body play a role in the production of estrogens and
relationship of cancer with blood type, although there act to increase the conversion of androgens induced The
was a disparity in the outcome, including the study of enzyme aromatase to estrogen, thus increasing levels
which found a relationship between blood type and of estrogen and its effect on the path of growth and
proliferation of other cells Thus natural development of
breast cancer. (figure 2)
estrogen-positive future cancers

Figure 2: Explain the relation between Blood group

Figure 4: Explain the relation between BMI and
and breast cancer
breast cancer
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 645
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Conflict of Interest: Nil 13. Stamatakos M., Kontzoglou K., Safioleas P.,
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Source of Funding: Self.

Ethical Clearance: Not required.

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DOI Number: 10.5958/0976-5506.2019.01647.4

Strengthen the Spiritual-Based Family Resilience to Overcome

the Family Stigma of Leprosy

Nasrudin1, Ah Yusuf2, Rachmat Hargono1, Tjipto Suwandi1

1
School of Public Health, 2School of Nursing, Airlangga University, Surabaya, Indonesia

ABSTRACT
The high burden of stigma received by the family as a result of leper family members requires resources,
support, and resilience so that the family will be able to perform its role in caring for the leper family
members and reducing the stigma. The Spiritual based family is an important component of the value
system and trust for family life in strengthening family resilience. This spiritual factor will be very
influential on coping, support, family acceptance of leprosy patients and the process of treatment and
family stigma.
The purpose of this research was to analyze family spiritual factor with family resilience theory approach in
overcoming family stigma.
This research used a cross-sectional design. The research population was 174 leprosy families in 21
endemic Leprosy public health centers or Puskesmas in Jombang regency of East Java. The samples were
120 families, taken using a Multi-Stage Random Sampling technique. The Hypothesis test used a chi-
square test with a p-value <0.05.
The result of the research was that 73 (60.8%) had moderate and high family stigma, 46 (52.5%) moderate
spiritual family and 60 (50%) of medium resilience. The family spiritual factor had an effect on family
resilience (P = 0.000), and family resilience had an effect on family stigma (P = 0.000).
The conclusion was that family spiritual factors influence family resilience to overcome family stigma.
Therefore, it is suggested that the intervention to overcome the family stigma must concern with family
resilience and family spiritual factors.

Keywords: Family, Spirituality, Resilience,

Stigma
Introduction has an effect on the family’s behavior of the leper family
members. The results of the previous research conducted
Based on the conceptual model of stigma, stigma
in 2017 showed that 39 families of leprosy patients in
is exists when the elements of labelling, stereotyping,
six endemic leprosy public health centers or Puskesmas
separation, loss of status, and discrimination occur in a
in Jombang regency of East Java had 29 (74.4%) family
power situation that allows stigma components to unfold
(1)
stigma, individual factors involved individual stigma,
. The cause of stigma in leprosy patients is complex,
self-concept, and level leprosy defect had an impact
namely socio-cultural, fear of the causes, manifestations,
toward the family stigma (P = 0.000). Family factors
effects and death from disease, economic, psychological,
involved family support, family coping mechanisms,
religious and spiritual (2,3). Public stigma effect on the
knowledge and family perceptions of leprosy had an
family raises stigma problems for the family and
impact toward the family stigma (P = 0.000) (4).
also
Resilience, support, and strengthening of family
Corresponding Author: resilience are needed by the family in carrying out the
Nasrudin family function of caring for the leper family members
Doctoral Student of Health Science, and overcoming the stigma for the family, family
Faculty of Public Health, Airlangga University, internal stigma and stigma for the lepers. Strengthening
Jombang regency of East Java Indonesia of family resilience includes three major components
Email: [email protected]
648 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 648

are namely: strengthening the family belief systems, lepers in the family. Assessment topics included 1). The
strengthening the structure and function of the family as family spiritual factor, 2). The family resilience, and
a unit or system (organization patterns), strengthening 3). The family stigma. The family spiritual factor data
communication patterns and family strength system assessed using the family’s answer to family religiosity
in overcoming problems (communication/problem- coping, family interdependence in religious and
solving) (4–10). Family spirituality is the basis of family spiritual, family support and togetherness in religious
values and belief systems, the core of all coping and and spiritual, and family spiritual. The family resilience
family adaptation, and families seek and rely on the assessed using the family’s answer to the family’s
spiritual support of family members as a family way ability to helping others, growing stronger, acceptance,
to deal with stigma problems (11–13). Spiritual is also a adjustment, and survival. The questionnaire used to
measure the spiritual family was a modified instrument
family domain, that being a source of family strength
which was created from the religion and problem-
and family resilience, hence this research was aimed to
solving scale (RPS) instrument based on the concept of
analyses family spiritual factor with family resilience
religion and the problem-solving process (14),the spiritual
theory approach in overcoming family stigma.
response questionnaire from Nursalam (15), and
the
Material and Method American Family Strengths Inventory on the component
Spiritual Well-Being (SWB) (16,17). The family resilience
This cross-sectional design research was conducted measurement questionnaire used the Walsh Family
on 2018 – 2019. The study population was a Resilience Questionnaire (WRFQ) (18) and the concept
leprosy
of family resilience processes (19). Measurements of
family in 21 endemic leprosy community health
family stigma were based on the concept of (20),
services in Jombang regency of East Java, consisted stigma
the concept of stigma and social stigma components
of 174 families of leprosy patients and they had been (21,22)
, and the concept of family stigma (23) and modified
diagnosed with leprosy and recorded in a public health
with the Explanatory Model Interview catalog (EMIC )
center or puskesmas data registration. The sample
stigma scale for community (24–27)
was 120 families taken by using Multi-Stage Random
Sampling. The hypothesis test was taken by using the The univariate analysis used frequency distribution
chi - square test with <0.05 significance. Data collected while bivariate analysis applied test chi-square if
by questionnaires. Respondent from each family was statistically eligible, if it does not qualify, then it would
represented by a family member who cares directly for use the test of Fisher’s Exact Test of p value <0.05.

Findings

The Family Spiritual Factors toward the Leprosy Family Resilience Analysis

Table 1: The Influence of family spiritual factor toward the leprosy family resilience in Jombang district
East Java Indonesia in 2018

Lower Moderate
High Resilience Total
Family spiritual Resilience Resilience P
(f) (%) (f) (%) (f) (%) (f) (%)
Family Religious Coping
Low 22 18.3 28 23.3 2 1.7 120 100
Medium 7 5.8 22 18.3 19 15.8 120 100 0.000
High 1 0.8 10 8.3 9 7.5 120 100
Family Interdependence in religious and spiritual
Low 20 16.7 22 18.3 0 0 120 100
Medium 9 7.5 28 23.3 22 18.3 120 100 0,000
High 1 0.8 10 8.3 8 6.7 120 100
Conted…

Family support and Togetherness in religious–spiritual

Low 27 22.5 28 23.3 0 0 120 100
Medium 2 1.7 23 19.2 21 17.5 120 100 0,000
High 1 0.8 9 7.5 9 7.5 120 100
Family Spiritual
Low 19 15.8 20 16.7 0 0 120 100
Medium 10 8.3 28 23.3 20 16.7 120 100 0,000
High 1 0.8 12 10 10 8.3 120 100

Based on table 1, it was shown that the spiritual family and its sub-variable influence the family resilience
(P=0.000). It can be seen that the Family Religious Coping, the Family Interdependence in religious and spiritual,
the Family Support and Togetherness in Religious and spiritual, and the Family Spiritual have a significant
influence on family resilience.

The Resilience Factor toward the Stigma of Leprosy Family Analysis

Table 2: The Influence of resilience factor toward the stigma of leprosy family in Jombang district of
Indonesia in 2018
Lower Stigma Moderate Stigma High Stigma Total
Family resilience P
(f) (%) (f) (%) (f) (%) (f) (%)
Helping other
Low 16 13.3 15 12.5 8 6.7 120 100
Medium 26 21.7 17 14.2 9 7.5 120 100 0.064
High 5 4.2 14 11.7 10 8.3 120 100
Growing stronger
Low 28 23.3 6 5 1 0.8 120 100
Medium 19 15.8 25 20.8 12 10 120 100 0.000
High 0 0 12.5 14 11.7 120 100
Acceptance
Low 26 21.7 13 10.8 4 3.3 120 100
Medium 19 15.8 32 26.7 14 11.7 120 100 0.000
High 2 1.7 1 0.8 9 7.5 120 100
Adjustment
Low 25 20.8 9 7.5 2 1.7 120 100
Medium 21 17.5 25 20.8 12 10 120 100 0.000
High 1 0.8 12 10 13 10.8 120 100
Survival
Low 41 34.2 13 10.8 2 1.7 120 100
Medium 6 5 25 20.8 15 12.5 120 100 0.000
High 0 0 8 6.7 10 8.3 120 100
Based on table 2, showed that the influence of spiritual family on family resilience after the statistical test,
obtained value P = 0.000. It can be deduced that Family Interdependence in religious and spiritual factors. The
family support and togetherness in religious and spiritual and the family Spiritual have a significant influence on
family resilience.
The percentage of the family spiritual and the family Family resilience is the ability to bounce back from
resilience rates were almost half at moderate (> 45%) adversity and then become stronger and able to take
and only a small (<20%) rate was high. The results lessons from the difficulties encountered. There are
indicated that the spiritual family which was the family three major components of family resilience, namely:
resources on the family’s basic value system was still family belief systems, family structure and function as
weak. Thus, these factors lead to family endurance to an organizational pattern, communication pattern and
stress and resilience family. family strengthening system (communication/problem-
After the statistical test, it was obtained that the effect solving) (6,9,28,31).
of family resilience of family stigma in table 2 was
P = Apparently, the reducing of leprocy occurences still
0.000, which means that family resilience has an effect on gives bad stigma about the lepers and their family to
family stigma. The influence of sub-variable of resilience the people and it is always attached to them. This effect
of the family was only sub-variable of other helping have of leprocy in term of physic, psychology and social
a p-value = 0.064, while sub-variable Growing stronger consequently contribute to the rise of the problem of
(P lepers and their family which represents in the form of
= 0.000), Acceptance (P = 0.000), Adjustment (P = stress and its effect on the health of the family. Thus,
0.000) and Survival (P = 0.000) it was concluded that resources, support and strengthening the resilient of the
there was influenced by the family stigma. family is necessary for the family of the lepers to care of
their members who suffers of leprocy and also to
maintain the health of the family. Furthermore,
Discussion
family should have spiritual control which is a based on
The family spirituality greatly influences the value system and family belief. In this case spiritual
family’s ability to deal with their problems, strengthens belief, family and individual religiousity are the core of
family relationships and the resilience reflected in all copings and family adaptation. Moreover, family try
family dynamics as a system in carrying out family to look for and use family spiritual belief to cope with
functions, the parenting styles, the family dynamics, stigma problem. In general, main concept of family
the family development, and the spiritual relationships spiritual consists of family religious coping, family
between generations. The spiritual component of the interdependence, family togetherness dan personal
family includes 1) The Personal faith; 2). The Spiritual spiritual (32,33)
and religious praxes (contemplative practices, rituals,
and ceremonies); 3). The Faith communities; (4) Conclusions
The Faith communities, connection with nature 5).
The Ability to express creative activities (expression The spiritual family includes the family religious
through the creative arts); 6). The Community service/ coping, the family interdependence in religious and
social activism; 7. The intimate relationship with spiritual, the family support and togetherness in religious
transcendence; 8). The Relationship with God (6,28). and spiritual, and the family member spiritual influence
on the occurrence of family resilience as well as the
Spiritual strength would strengthen family health,
stigma to the family with the leper.
including family commitments, improve emotional
health, develop healthy living behaviors, improving Conflict of Interest: There is no conflict of interest for
healing process (13). The spiritual influence 4 every author
dimensions of family care which were coping, support,
acceptance, treatment and treatment process (29). This Source of Funding: This research was funded by
condition cause a stressor of the situation for the Directorate for Research and Community Service,
family, the ability of the family to survive or the Directorate General of Development and Research
ability of family resilience is needed in the overcoming Enhancement, The Ministry of Research, Technology
a stressful situation, the ability of the family to adapt, and Higher Education.
help each other, accept the condition of leprosy patients,
change the family structure that support the process of Ethical Clearance: All procedures performed in studies
treatment and care as well as the ability to survive involving human participants had gotten ethical approval
together will help families to solve problems and adapt from the Health Research Ethics Committee, Faculty of
to stressors and will not appear in family stigma (7,28,30). Public Health Airlangga University
Informed Consent: Informed consent was obtained Well- Being : Testing a Theory of Family
from all individual participants included in the study. Interdependence Among Family Caregivers and
... Spirituality and Psychological Well-Being
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DOI Number: 10.5958/0976-5506.2019.01648.6

Association between Socio-economic Status and Breast Feeding

Practices in a Group of Women Delivered During the Previous
Year in Kirkuk City

Nazar Ahmed Mahmood1, Qasim Husein Mohammad1, Kasim Sakran Abass2

1
Department of Basic Nursing Sciences, College of Nursing, 2Department of Pharmacology and
Toxicology, College of Pharmacy, University of Kirkuk, Kirkuk, Iraq

ABSTRACT
Breastfeeding is considered as an ideal form of feeding in the neonate. It is feeding of babies with breast
milk directly from women breasts instead of a baby bottle or other container. The present study aims at
investigating the association between breastfeeding practices and socioeconomic status. This cross-
sectional study was conducted at Pediatric General Hospital (PGH) in Kirkuk city over a period of seven
months starting from January 2016. Consecutive sampling was employed to collect 377 mothers who have
children (< 24 months) in PGH. A questionnaire was used to compile the information on the socio-
economic factors and practices of breastfeeding. Data was analyzed through descriptive and inferential
statistics (Chi-square test). Out of 288 mothers, 377 of them reported being breastfed. A significant
difference has been found between breastfeeding practices and some maternal data. These include age (p
<0.001), parity (p= 0.018), and antenatal session attendance (p <0.001). On the other hand, the regular visit
to the PHC during the prenatal period did not affect breastfeeding practices (p= 0.296). Moreover, a highly
significant association between breastfeeding practices and socioeconomic status of mothers has been
shown. These include educational level (p= 0.002), occupational status (p <0.001), and family income (p
<0.001). Breastfeeding has increased significantly with the increase in the level of education, family
income, and being an employee.

Keywords: Breastfeeding, Income, Education, Employment.

Introduction Breastfeeding is considered an important measure to
secure optimal health and survival for children.4 Breast
Breastfeeding is the process of feeding human
milk is the optimal food for infants and its benefits are
breast milk to an infant. It is the usual way to provide
numerous, as they contain living components such as
babies with the nutrients they need to ensure healthy
antibodies that fight infection, white blood cells, red
growth and development in the future.1 Worldwide
blood cells, and antiviral agents.5 Moreover,
almost 38% of babies are just breastfed during their first
breastfeeding is a protective factor for chronic diseases
six months of life. The duration of breastfeeding is
that may occur later in life, such as diabetes, childhood
shorter in high- income countries than in those that are
asthma, obesity, high cholesterol, high blood pressure,
resource-poor.2
and childhood leukaemia. As of intelligence and behavior
In Iraq, the early initiation rate of breastfeeding has
in adulthood, it has been shown that breastfed infants
risen from 25.1% in 2006 to 43% in 2011, whereas the
achieve better results in the tests compared to infants who
exclusive breastfeeding rate was only 20%. 3
are formula-fed.6

The mothers likewise are no exception of

Corresponding Author: breastfeeding benefits, it contributes to a lower risk
Kasim Sakran Abass of postpartum bleeding; maintains birth spacing;
Department of Pharmacology and Toxicology, strengthens mother-infant relationship; and finally
College of Pharmacy, breastfeeding provides money and effort, as breast milk
University of Kirkuk, Kirkuk, Iraq is ready and needs no preparation.4 In addition, it
Email: [email protected] protects against certain non-communicable diseases
such as
654 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 654

heart disease, type 2 diabetes, breast cancer, endometrial proportion,12 a 95% confidence level, a prevalence rate
cancer, and ovarian cancer.6 of 43%,14 and a 5% allowable point of error, a sample
size of 377 was arrived at. So, consecutive sampling
There is evidence showing that breastfeeding
was done on mothers who met the inclusion criteria
practices are influenced by many factors such as
from Pediatric General Hospital until the sample size
maternal age and higher parity. It has been shown that
was reached. Exclusion criteria were mothers who have
older mothers and higher parity are the strongest
predictors of exclusive breastfeeding.7,8 Socioeconomic not to breastfeed their babies due to barriers other than
status such as income, education, and employment also socioeconomic factors. A questionnaire was constructed
turn up affecting breastfeeding practices.9 It has shown to reach the purpose of the study. It consisted of three
that rates of breastfeeding increase with high family parts; the first part concerned with mothers’
incomes.10 demographic attributes (age and parity), and maternal
It was thought that parents, who are employed, have a socioeconomic information (education, occupation,
higher level of education, and a higher income may have and income). The second part was supportive
more positive attitudes towards breastfeeding 11 which activities (visiting PHC regularly during pregnancy and
in turn may lead to breastfeeding practices. Wherefore, participating in lectures regarding breastfeeding), and
the findings of this study would provide a database to the last part was relating to breastfeeding practices.
the stakeholders in Iraq to design such an intervention Family income was categorized as Low income (<
programme to improve the practice of breastfeeding in 500000 ID), Adequate (500000-1000000 ID), and High
the area with similar circumstances. income ( > 1500000). The content validity the
questionnaire was determined through a panel of ten
Method experts. The questionnaire was piloted on 10 mothers
who have been excluded from the final sample. The
Across-sectional study has been conducted at Statistical Package for Social Sciences software
Pediatric General Hospital (PGH) in Kirkuk city over (SPSS, version 21) was used for data processing and
a period of seven months starting from January 2016 to statistical analysis. Data was analyzed through
the end of July 2016. The target population was mothers descriptive (frequency and percentages) and inferential
in Kirkuk city with children (< 24 months). Utilizing the statistics (Chi-square test). A P value of ≤0.05 was
sample size formula N= Z² x P x (1-P)/ d² for considered statistically significant.
single
Results

Table 1: Association of breastfeeding practices with some maternal data of (377) sample

Breastfeeding
Characteristics Total P value
Practiced Not practiced
Age (Years) No % No % No %
18-21 24 8.3% 5 5.6% 29 7.7%
22-25 50 17.4% 16 18.0% 66 17.5%
26-29 32 11.1% 12 13.5% 44 11.7% <0.001
30-33 71 24.7% 46 51.7% 117 31.0%
34-38 111 38.5% 10 11.2% 121 32.1%
Total 288 100% 89 100% 377 100%
Parity No % No % No %
Primiparous 80 27.8% 36 40.4% 116 30.8%
0.018
Multiparous 208 72.2% 53 59.6% 261 69.2%
Total 288 100% 89 100% 377 100%
Visiting PHCc No % No % No %
Available 211 73.3% 62 69.7% 273 72.4%
0.296
Un available 77 26.7% 27 30.3% 104 27.6%
Total 288 100% 89 100% 377 100%
Conted…
Lectures Attendance No % No % No %
Available 203 70.5% 50 56.2% 253 67.1%
0.009
Un available 85 29.5% 39 43.8% 124 32.9%
Total 288 100% 89 100% 377 100%

N= number; %= percentage; P = level of probability ≤0.05

More than half of mothers (63.1%) have aged 30 A significant difference has been found between
years and over, (69.2%) of them have more than one breastfeeding practices and some maternal data. These
child, a vast majority of mothers (72.4%) have regularly include age (p <0.001), parity (p 0.018), and antenatal
visited primary health care center (PHCc) during lectures attendance (p 0.009). On the other hand, regular
antenatal period, and (67.1%) of them have received visit to (PHCc) during antenatal period has not affected
antenatal orientation about breastfeeding. A total of 288 breastfeeding practices (p 0.296).
mothers out of 377 reported being breastfed (Table 1).

Table 2: Association of breastfeeding practices with maternal socioeconomic status of (377) sample
Breastfeeding
Characteristics Total P value
Practiced Not practiced
Educational level No % No % No %
Illiterate 36 12.5% 6 6.7% 42 11.1%
Read and write 15 5.2% 5 5.6% 20 5.3%
Primary school 43 14.9% 19 21.3% 62 16.4% 0.002
Secondary school 11 3.8% 13 14.6% 24 6.4%
Institute graduate 14 4.9% 6 6.7% 20 5.3%
College and above 169 58.7% 40 44.9% 209 55.4%
Total 288 100% 89 100% 377 100%
Occupational status No % No % No %
Housewife 88 30.6% 47 52.8% 135 35.8% <0.001
Employee 200 69.4% 42 47.2% 242 64.2%
Total 288 100% 89 100% 377 100%
Family Income No % No % No %
Low income 12 4.2% 43 48.3% 55 14.6%
Adequate income 233 80.9% 35 39.3% 268 71.1% <0.001
High income 43 14.9% 11 12.4% 54 14.3%
Total 288 100% 89 100% 377 100%
N= number; %= percentage; P = level of probability ≤0.05
The findings of (Table 2) have been illustrated a help children to fight microbial agents.5 For mothers, it
highly significant association between breastfeeding protects against uterine cervical and ovarian cancers as
practices and socioeconomic status of mothers. These well as breast cancer.6 Breastfeeding is influenced by
include educational level (p 0.002), occupational status several factors. The decision to breastfeed is associated
(p <0.001), and family income (p <0.001). with higher socioeconomic status.9 A present study was
designated to describe the influence of socioeconomic
Discussion status on breastfeeding practices among mothers
attending PGH in Kirkuk city. It used educational level,
Breastfeeding is considered as an ideal form of occupational status, and family income as indicators of
feeding in the neonate. It is a protective factor for both socioeconomic status. It has shown a significant increase
mothers and children because it contains antibodies that of the breastfeeding practice with an increasing level of
education and family income. This means uneducated related to ineffective breastfeeding and the benefits
women, and those with low income are usually less of
inclined to breastfeed their infants. The possible breastfeeding to mother, baby, and society as well.24
explanation for this finding is that uneducated mothers
are at lower risk of social variables as a result of their In conclusion, socioeconomic status is responsible
contact with the community, and because of the lack of for such findings. Breastfeeding increased significantly
their health knowledge, they have fed their babies other with increasing level of education, family income,
than breast milk. This is because the mothers who have and being an employee. The study findings highlight
more education may understand the health benefits of the need for raising the level of women’s education,
breastfeeding.14 This finding confirms previous similar expanding the chances for women to work can increase
studies,10,15,16 while in contrast to others elsewhere.17,18,19 the income of the household which in turn participates
This variance perhaps results from differences in the in the financial stability for the families, and designing
pattern of breastfeeding among women in different appropriate programmes for new parents to show the
cultures. Another reason may be that mothers in those importance of breastfeeding and its benefits (e.g., social,
studies are more inclined to breastfeeding compared psychological, and economic benefits) for mothers and
to other mothers. Furthermore, mothers’ practices of babies in addition to showing the disadvantages of
breastfeeding have been affected by their occupation. skipping breastfeeding.
It has shown mothers who work were more likely to Conflicts of Interest: The researcher reports no conflicts
breastfeed their babies than housewife mothers. This of interest.
finding is coincide with that reported by other
studies.15,20 Conflict of Interest: None of the authors have any
The explanation for this finding could be attributed to conflicts of interest to declare.
several reasons. First of all, in Iraq, a period of up to
Source of Funding: The research was performed
one-year maternal leave is given to female workers for
independently, there is no funding, influence over study
taking care of their newborns. Second, during working
design, analysis, manuscript preparation, or scientific
hours, a nursing break of up to one hour is given for
publication.
nursing mothers for the same reson.13 The third reason
is that parents, who are employed, have a higher level of Ethical Clearance: The project was approved by
education, and a higher income may have more positive the
attitudes towards breastfeeding.11 local ethical committee in University of Kirkuk.
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England: an analysis by primary care trust. BMJ
open 2013; 3(6):e002765.
23. Kitano N, Nomura K, Kido M, Murakami K,
Ohkubo T, Ueno M, Sugimoto M. Combined
effects of maternal age and parity on successful
initiation of exclusive breastfeeding. Preventive
medicine reports 2016; 3:121-6.
24. Shealy KR, Li R, Benton-Davis S, Grummer-
Strawn LM; the CDC Guide to Breastfeeding
Interventions. Atlanta: U.S. Department of Health
DOI Number: 10.5958/0976-5506.2019.01649.8

Quantitative Assessment of Factors Affecting Visual Acuity by

Changing the Luminance

Osama Q. Abdullah1, Fadia W. Al-Azawi2, Sara T. Hassan3

1
Dijlah University College, 2Al-Karkh University of Science, 3Alrafidain University College

ABSTRACT
In today’s deregulated, the world continues its voyage towards modernization, and there is a great demand
for inventive in product and services development, Visual acuity measurement has become one of the most
successful clinical tests of visual function, Visual Acuity (V. A) Commonly refers to the clarity of vision, in
another dimension, although V. A. is an estimate of the visual system’s ability to resolve the details.
However, the estimates of Visual acuity are taken by evaluating and measuring the eye’s ability to realize
and resolve varying sizes of letters and shapes in Snellen’s chart. More recently attention has focused on the
luminance of the visual acuity chart while it is essential to consider the overall room illumination during
visual acuity measuring. It has commonly been assumed that the rise in ambient room illumination
decreases the size of the pupil. A smaller pupil increases the depth of focus furthermore reductions the
peripheral light rays that entering into the eye. Thus, the reduced pupil diameter great less spherical
deviation and other higher order aberration, such as coma aberration. A clinician may achieve an
artificially better estimate of visual acuity in a brightly-lit examination room. The aims of this study is to
determine the factors affecting Visual Acuity by changing the luminance. Fourteen patients aged 19 to 24
years were chosen. Monocular visual acuity patients were assessed under five different luminance levels
(different colors), and V. A was measured in the patients with each room color. The results showed that
there is a clear difference in the measurement of V. A when the light was changed from color to another.
The visual acuity of patients was assessed using the five different levels of illumination.

Keywords: Visual Acuity, luminance, Snellen

chart

Introduction information is done by the system of the human visual.

Moreover, it had been found in studies that inappropriate
Visual acuity is an estimate of the visual system’s
illumination will increase the attention fatigue,
ability to resolve fine details. Visual acuity estimates
reductions the performance, and eventually ends up in
are taken by assessing and quantifying the eye’s ability
an incident. If environmental conditions, specifically
to recognize and resolve the letters of varied sizes and
illumination, cannot meet the individual’s
shapes[1]. There are numerous environmental factors
performance necessities, it’ll cut back the quality of
which might influence the operator’s performance within
performance and result in the prevalence of errors[3-6]..
the control-room and cause errors. Conditions of work
Thus, making valid illumination is significant to AN
surroundings like sound, illumination, and heat have a
individual’s correct performance. Varied illumination
crucial impact on people’s attitudes, performance and
factors (such as color temperature and intensity) have
behavior[2]. Visual performance is critical for control-
an effect on the individuals’ visual and psychological
room operators thanks to most of the activities in the
feature performance[7].Varied factors like color
process the
distinction, illumination level, individual
variations, viewing time, gazing and etc., Are in the
Corresponding Author: result of visual performance[8].The individual’s potency
Fadia W. Al-Azawi within the control-room is directly littered with visual
Lecturer, Al-Karkh University of Science performance. People would like sensible illumination
Phone: +964 7901966308 within the control-rooms to possess AN acceptable
Email: [email protected] vision[9]. During this study, the results showed that
there’s
659 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 659

a marked distinction within the measured optical

intensity once ever-changing the space lightweight from
color to a different color. Considering the potential
disadvantages of measuring visual acuity below the
bright area illumination with the traditional display,
totally different intensities of sunshine with different
wavelengths (traditional light, yellow light, red, green,
and blue) were chosen and therefore the comparison for
visual acuity among these sources of illumination was in
deep trouble the identical patients. For this reason, this
subject was chosen to attain this, the project to line
the influence of adjusting brightness on visual acuity. (a)
Fourteen patients aged nineteen to twenty-four years
were assessed. Monocular visual acuity patients were
assessed underneath 5 totally different brightness levels
(different colors), and V. A was measured within the
patients with every area color. The results of the
examination in patients showed that there’s a transparent
distinction within the mensuration of V. A once the
sunshine was modified from color to a different.
2.0.

Materials and Methodology (b)

Twenty-eight eyes of adults’ students were

examined in Dijlah University College/Optics
techniques department/Refractive errors laboratory.

Essential colors were used to achieve this, the

project as in the following tables and figures. These
colors are different in colors which are related to
wavelength, then energy [10].
The energy © of each color can be calculated using the
Plank’s equation:
(c)
E = h ʋ = hc/ʎ …(1)
Where:
h: Plank’s constant = 6.63*10-34 m2 kg/s
ʋ: Frequency of the light.
C: Speed of the light in vacuum = 3*108 m/s2
ʎ: Wavelength of light (nm)

Table 1: The color spectrum used in this study

Color Wavelength (nm) E (e V)

Red ~ 700- 635 < 1.77
Yellow ~ 635 -590 2.14 (d)
Green ~ 590- 560 2.34 Figure 1: (a, b, c, and d): Examination room with
different sources of light
Blue ~ 520- 490 2.64
Figure 2: Percentage of the selected cases, according to gender

Figure 3: The age of the selected cases ranged between (19-24) years

Each patient was seated in front of the chart and the V. A is measured for each eye separately, first the right eye
examined and the left eye closed by occluding then the right eye closed and the left examined.

The examination process repeated for every patient over a wide range of illumination (traditional, red, green,
blue, and yellow) to study the effect of wavelength of each stimulus on the vision and to improve that one of the
V.A. Problems its emphasis on fovia under one level of illumination furthermore one distance.

The examined patients selected randomly as the percentage shown in figure (2) 43% for male and 57%
for
females and them ages ranged between (19-24) years old as shown in figure (3).

Table 2: patients’ properties and their response to essential colors

V.A. over a wide range of room illumination

Case No. Gender Age Eye
Traditional Red Green Blue Yellow
R CF 2m CF 5m CF 5m CF 3m CF 3m
1 F 19
L CF 3mp CF 5m 6/60 p CF 3m CF 4m
R 6/9 p 6/9 6/12 6/12 6/12p
2 M 21
L 6/6 6/6 6/9 6/9 6/9p
R 6/9 p 6/6 6/6p 6/6p 6/9p
3 F 22
L 6/24 6/36p 6/18p 6/36 6/36p
R 6/36 p 6/36p 6/36p 6/36p 6/60
4 M 22
L 6/6 6/9p 6/6p 6/6p 6/6p
R 6/9 p 6/6 p 6/9 p 6/9 p 6/12 p
5 F 19
L 6/6 6/6 6/6 6/6 6/6
R 6/6 6/6 6/6 6/6 6/6 p
6 M 22
L 6/6 6/6 6/6 6/6 6/6
Conted…
R C.F 2m C.F 2m C.F 2m C.F 2m C.F 3m
7 M 20
L 6/9 6/12 6/9 6/12p 6/18
R 6/6 6/6 p 6/6 6/6 6/6
8 F 20
L C.F 2m C.F 2m C.F 2m C.F 3m C.F 4m
R C.F 6m C.F 5m C.F 6m C.F 5m C.F 6m
9 M 24
L 6/6p 6/6 6/6 6/6 6/6
R C.F 6m C.F 5m C.F 3m C.F 6m C.F 6m
10 F 21
L C.F 6m C.F 3m 6/60 C.F 6m C.F 4m
R 6/6 6/6 6/6 6/6 6/6
11 F 20
L C.F 3m C.F 3m C.F 3m C.F 2m C.F 6m
R C.F 2m C.F 2m C.F 2m C.F 2m C.F3m
12 M 20
L C.F 2m C.F 2m C.F 3m C.F 6m C.F 4m
R 6/9p 6/18p 6/12p 6/18 6/12
13 F 20
L 6/9 6/12 6/9 6/12p 6/1
R 6/6 6/6 6/6 6/6 6/6
14 F 23
L C.F 3m C.F 6m C.F 2m C.F 1m C.F 2m
Where: M: Male, F: Female, C.F: Count Finger, P: Partial
Results & Discussions The investigate the consistency of visual acuity
under different ambient room illuminations.
The results obtained at the table (1) showed that
there is an opposite relationship between the wavelength The findings of this study demonstrate that changes
of the light and its energy. The red color which has in luminance have an influence on VA that may
the longer wavelength has the minimum energy while contribute to test/retest variability.
the blue light which has the minimum wavelength has
higher energy. Ethical Clearance: This paper done under Ethical
Approval is Required by our universities.
The examination with eye chart is quite satisfactory,
but this is obviously incomplete. It emphasizes on fovea Source of Funding: By ourself
vision, usually at one level of illumination in order to be
Conflict of Interest: There is no any potential conflicts
complete, in this study, the effect of the illumination was
of the manuscript
studied over a wide range of illumination.

The results of this study show that correct REFERENCES

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6. Juslén H, Tenner A. Mechanisms involved in 10. Deshmukh, P. C., & Venkataraman, S., 100 years
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Ergon. 2005;35(9):843–55. two parts: September & October Issues of (2006).
DOI Number: 10.5958/0976-5506.2019.01650.4

Effect of Adding Probiotic with Different Levels of Citric Acid

in Feed Supplementation to Laying Hens on Bacteria Content
of Feed, Litter and Egg Shell

Rashid H. hameed Al-Dalawi1, Qana Hussein ameen1, Mahdi Salih Jasim1

1
College of Agriculture, University of Kirkuk, Iraq; 2College of Agriculture, University of Dayala, Iraq

ABSTRACT
Study conducted to determined effect of adding Probiotic (Iraqi Probiotic) with different levels of citric
acid to Lohmann brown laying hens in order to know the effect of addition on the microbial content of the
feed, litter and eggshell. The treatments were T1 without any addition (control), T2 (0.25) probiotic, T3, T4
and T5 add Probiotic each with a fixed level of 0.25% with levels 0.15, 0.30, 0.45% of citric acid
sequentially. The Addition of probiotic with citric acid led to a significant decrease (p <0.05) in both (Total
count bacteria) and (Coliform bacteria) in feed and litter compared with the control treatment and the
treatment of adding probiotic alone. The addition of either alone or with citric acid lead to a significant
decrease in the total number of aerobic bacteria on the eggs product and no effect on the number of E.coli
in the eggs product.

Keywords: probiotic, citric acid, laying hens, feed, eggs shell, litter, bacteria
Count
Introduction fruits have a pH of about 2.5 due to the presence of citric
acid (58 mg/mL). The acidity of the lemon fruits is due
Poultry industry represented in last years quick
to the accumulation of this acid (7). Organic acids have
developments in using various factors to increase
been used for many decades to preserve food and
productivity and these factors used are antibiotics to
prevent the growth of pathogenic microbes (8,9) for the
stimulate the growth, protection and treatment of
effectiveness of these acids in reducing the pH of the
domestic poultry from disease (1) However, this
substances mixed to the level that affects the
development has increased the animal’s susceptibility
environment of pathogenic bacteria (10). It has been used
to disease (2). As well as the world orientation in recent
in the field of animal and poultry production as an
years to prevent using of antibiotics to stimulate
effective and safe alternative to antibiotics used to
production (3). Therefore, it was necessary to use
stimulate growth, improve immunity and prevent the
alternative methods of antibiotics in breeding. From
infection of many intestinal diseases and additives to
these substitutes have been use as Probiotic and acids
feed and drinking water for domestic birds (11). Adding
including citric acid to stimulate growth and increase
of formic acid in level 0.5% to feed resulted in a
production of meat and eggs. as well as reduce the level
reduction of pH to 6.62 compared to7.38 for control
of mortality by raising the immunity of the body as well
treatment, (12) study effect of adding Gallia acid
as improving the conversion factor and protection
(mixture of fumic acid, Formic, calcium propionate and
against bacterial infection (4). Probiotic is a living
Sorbic acid) by 1 g/kg feed, the preparation of bacteria
colonies of beneficial microorganisms, whether bacteria,
strptococcus Lactobacillus in the intestines noticed
yeast or fungus, which when introduced in sufficient
a significant increase in the preparation of bacteria
quantities within the host, attached to the receptors
Lactococcus when adding the product compared to the
located on the surface of the lining cells of the adrenal
control and thus enhance the role of the Probiotic when
duct, thereby preventing the adhesion of harmful
it used to promote production in poultry and the use of
microorganisms (5) and (6). Organic acids are a type of
alternatives to additives antibiotics in poultry feed (13).
fatty short chain. Organic acids are naturally formed in
The aim of this study was to conduct the effect of adding
plants as a result of metabolic processes and are found in
Probiotic with organic acid to layer chicken ration on the
different cells in varying amounts. For example,
bacterial count on feed, letter and egg shell.
lemon
664 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 664

Materials and Method acid, 2.2 mg; thiamine, 4 mg; pyridoxine, 8 mg;
And biotin, 252 ug.3Selenium premix contained
The experiment carried out in the field of
sodium selenite (Na2SeO3), roviding 0.3 mg/kg.
poultry
for 150 days by using of 195 Lohmann brown z Data expressed on a percentage of dry matter basis.
layers Formulations Confirmed by proximate analyses
20weeks old were rearing in cages and fed on a standard
productivity diet (Table 1). The birds were distribute on The samples of feed, letter and eggs collected every
five nutritional treatments 30 days (5 replicates) by taking samples from different
places of feed for each treatment after mixing well.
T1: (Control treatment) standard ration. The samples were placed in sterilized polythene bags.
After that, 10 g of each sample was added and the saline
T2: Standard ration with 0.25% of Probiotic.
solution was added in the sterile conditions and worked
T3: Standard ration supplemented with 0.25% of decays to 10-9 dilutions, and the same method was taken
Probiotic + 0.15 Citric Acid%. in taking samples from the mattress as samples of the
mattress were taken from different places of each cage
T4: Standard ration with 0.25% Probiotic + 0.3 Citric in which birds were breeding and samples were placed
Acid%. in sterile bags and worked the same dilutions. IN order
T5: Standard ration with 0.25% Probiotic + 0.45% Citric to estimate the number of bacteria on the eggshell, the
samples were collected by taking five eggs from each
Acid.
treatment, if there was no delay in collecting the eggs.
The Probiotic used is the Iraqi Probiotic, the The samples of each treatment were then placed in a
microbiology was Lactobacilli, and Lactobacillus sterilized bag and the solution was added 100 ml. Take
acidophilus, Bacillus subtitlis, and saccharomyces 10 ml of suspension and dilute decimals until 10-9.
cerevisia yeast, Citric acid was 99% concentration. Bacterial content per cm2 of egg surface was calculated.
The spreading plating method (14) was followed by
estimating both the numbers of coliform bacteria and
Table 1: Ingredients using in diet and chemical
the preparation of total bacteria, and the concentrations
composition of it
of these organisms were converted to logarithmic
Composition Percentage % numbers of base 10 and expressed as Log10 cfu/gm for
Corn 63.7 feed and letter. As for the bacterial preparation on the
Soybean 26 surface of the eggshell, it was expressed by Log10 cfu/
Calcium 2.5 cm2 according to the method (15), using the following
equation: S = 4.68 W2/3
Die phosphate 7.5
Nacl 0.3 z Where S = the outer surface of the eggshell
(cm2)
Chemical Composition
and W = the weight of the egg in grams.
Crude protein % 17
Energy k cal/kg 2740 To measure of Ph for feed, (16). method used by use
Methionine% 0.140 1 g of feed per treatment, add 10 ml of distilled water,
Lysine % 0.92 mix well, leave for 10 minutes at room temperature and
Calcium % 3.45 pH were measure by pH meter. The data were analyzed
using (17) using full random design (CRD) and the test of
Available phosphor % 0.63
differences between coefficients using the(18).
z Mineral premix contained the following in
milligrams per kilogram of diet: manganese, 120; Results and Discussion
zinc, 120; iron, 180; copper, 10; iodine, 2.5; Cobalt,
1.0.Vitamin premix contained the following The results of the statistical analysis in Table (2)
per kilogram of diet: vitamin A, 13,200 IU; showed that there was a significant effect (p<0.05) in
cholecalciferol, 4,000 IU; vitamin E, 66 IU; vitamin the total bacterial count of the microbial content when
B12, 4.6 ug; riboflavin, 13.2 mg; niacin, 110 mg; adding the Probiotic with different amounts of citric acid
pantothenic acid, 22 mg; vitamin K, 4 mg;
folic
compared with the treatment of control and treatment of and beneficial microbes. The results indicated in Table
the addition of the Probiotic alone, Treatment of (3) that the addition of the Probiotic with alastric
addition T5 was the lowest of the mean number of total acid resulted in a significant decrease (P <0.05) in the
bacteria followed by treatment T4 while the treatment number of total bacteria of the letter. T5 and T4 were
T3 and T2 did not differ significantly from the control scored the lowest values for the average number of
treatment. Table 2 also showed a significant decrease bacteria followed by treatment T3 while the treatment
in colonic bacteria in the addition of the Probiotic with of addition of the Probiotic alone didn’t different from
citric acid. The parameters T3, T4 and T5 showed the the control treatment. It is also noted from Table (3)
lowest values, which differed significantly from the that the number of colonic bacteria has continued to
control treatment without addition. decrease as we move towards the increase in the
addition of organic acid to the Probiotic as recorded
treatments T3, T4 and T5 significantly lower in the
Table 2: Effect of the addition of the biocomponent
preparation of E.coli compared to the treatment of T1
with different levels of citric acid to the egg-white and T2, due to the role of microbes in the Probiotic
chickpea on the bacterial content of the egg-white when the balance of these microorganisms within
chickpeas (5.65 log10 in m/g) The gastrointestinal tract increases its ability to compete
Total number of Number of for food with pathogenic microorganisms, (20,21). As well
Treatments as its ability to secrete microbial growth agents,
aerobic bacteria E.coli
T1 7.39 ± 0.26 7.65 ± 0.65 including Bactriocin, produced by Bifidobacterium, as
effective bilogia compounds and inhibiting the growth
T2 7.28 ± 0.19 5.31 ± 0.32
of bacteria such as toxins, antibiotics, and bactericidal
T3 6.98 ± 0.21 4.92 ± 0.72 enzymes (22). As well as the deadly and inhibitory effect
T4 6.44 ± 0.05 4.63 ± 0.62 of organic acid of pathogenic bacteria (23). By reducing
T5 6.15 ± 0.06 5.15 ± 0.43 PH for the acid- sensitive cytoplasmic cytotoxicity, this
Mean ± S.E will reduce the number of microbes present with
glaucoma and thus will decrease its presence in the
T1: (Control treatment) standard ration.
mattress of birds.
T2: Standard ration with 0.25% of Probiotic.
T3: Standard ration supplemented with 0.25% of Table 3: Effect of the addition of the biocomponent
Probiotic + 0.15%. Citric Acid. with different levels of citric acid to egg white
T4: Standard ration with 0.25% Probiotic + 0.3%. Citric chicken eggs in the bacterial content of the chicken
Acid. egg (log10 and L/g).
T5: Standard ration with 0.25% Probiotic + 0.45% Citric
Total number of Number of
Acid. Treatments
aerobic bacteria E.coli
From this table we see that there is a significant T1 6.99 ± 0.03 4.42 ± 0.04
decrease in the number of pathogenic bacteria. As the T2 6.86 ± 0.13 4.29 ± 0.08
percentage of addition of citric acid increased to the T3 6.78 ± 0.07 3.91 ± 0.04
Probiotic where the organic acid reduces the amount T4 6.71 ± 0.1 3.67 ± 0.02
of harmful bacteria by reducing the pH when added to T5 6.62 ± 0.05 3.55 ± 0.05
feed. Reducing the content Microbial, as the pathogenic
microbes do not grow in the acidic medium. Which Mean ± S.E
leads to the elimination of them and reduce their activity T1: (Control treatment) standard ration.
and reproduction through the destruction of the wall cell T2: Standard ration with 0.25% of Probiotic.
bacterial as well as disable the process of cloning the
T3: Standard ration supplemented with 0.25% of
DNA of the cell and disorder in many physiological
Probiotic + 0.15%. Citric Acid
functions of the cell (19). In contrast, beneficial bacteria
thrive more in acidic media, making them grow, thrive T4: Standard ration with 0.25% Probiotic + 0.3%. Citric
and compete with harmful bacteria and microbes Acid.
because of the constant competition between harmful T5: Standard ration with 0.25% Probiotic + 0.45% Citric
Acid.
From Table (4) we so that there is a significant Conclusion
difference between all additive treatments compared to
the control treatment for the preparation of total bacteria We consoled from this search that the addition
on the eggshell and there was no significant difference of either alone or with citric acid lead to a significant
between all treatments for the preparation of E.coli. decrease in the total number of aerobic bacteria on the
eggs product and no effect on the number of E.coli in the
Table 4: Effect of the addition of the biocomponent eggs product.
with different levels of alastric acid to the brown
Conflict of Interest: None
chicken lemehannum in the bacterial content of the
eggshell (log10 in C/cm2) Source of Funding: Self
Total number of Number of Ethical Clearance: Not required.
Treatments
aerobic bacteria E.coli
T1 7.61 ± 0.62 5.53 ± 0.63
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DOI Number: 10.5958/0976-5506.2019.01651.6

Occurrence of MBLs and Carbapenemases among MDR and

XDR Acinetobacter baumannii Isolated from Hospitals in Iraq

Safa Hasan Radhi1, Alaa H. Al-Charrakh1

1
Dept. of Microbiology, College of Medicine, University of Babylon, Hilla, Iraq

ABSTRACT
The current study was conducted to determine carbapenemase-producing Acinetobacter baumannii clinical
isolates recovered from two hospitals in Iraq. A total of 540 different clinical samples were collected.
Isolates were identified and Carbapenemase production were detected using MBL E-test, Modified Hodge’s
Test (MHT), and Modified Carba NP test. A total 30 A. baumannii isolates were obtained from clinical
specimens. It was found that 73.3% isolates were carbapenem resistant. Out of 30 A.baumannii
isolates,
22 (73.3%) isolates were confirmed to be MBL positive by MBL E-test method, 5(16.6%) by
MHT, and
27 (90%) isolates by Modified Carba NP test. Results revealed that 21 A.baumannii isolates (70%) were
found to be MDR and only 9 isolates (30%) were XDR. It can conclude that most of carbapenem resistant
A.baumannii clinical isolates were MDR. The CNPt assay was the most reliable among phenotypic assays
to detect MBL production.

Keywords: Acinetobacter baumannii, MBLs, Carbapenemases, MBL E-test.

Introduction Email: [email protected]

One of the greatest threats to modern medicine

is the increasing prevalence of antibiotic-resistant
bacteria, particularly Gram-negative bacteria(1-4). One
of these bacteria, Acinetobacter baumannii, has raised
to prominence due to the international dissemination of
multidrug-resistant lineages resistant to the carbapenem
antibiotics(5). Centers for Disease Control and Prevention
(CDC) recognizes MDR A. baumannii as a source of
global outbreaks especially due to its effectiveness in
colonizing hospital environments and due to its
increasing resistance to commercially available
antibiotics (6).

Mechanisms of resistance in Acinetobacter

strains
include efflux pumps, 𝛽-lactamases, and modifications in
porin proteins. Enzymatic degradation by 𝛽-
lactamases
is the most Prevalent mechanism of 𝛽-lactam resistance

in A. baumannii. Serine oxacillinases and metallo-𝛽-

Corresponding Author:
Prof. Dr. Alaa H. Al-Charrakh
Department of Microbiology, College of Medicine,
University of Babylon, Hilla, Iraq
Phone: 00-964-7816658072
lactamases (MBLs) are 𝛽-lactamases with carbapenemase
activity (7). The prevalence of MDR A. baumannii strains
have been increasing during recent years continually
and causing of highly mortal hospital infections (8). The
increase in drug resistance of Acinetobacter to the most
of antibiotics is resulting from abuse of antimicrobial
agents(9). Carbapenem resistance is now observed
worldwide in A. baumannii isolates, leading to limited
therapeutic options. Several carbapenem-hydrolyzing
lactamases have been documented in A. baumannii.
Lactamases from class B illustrate highly hydrolyzing
activity of carbapenems (10).

The aim of this study was to investigate the

characterization of Carbapenemase–Producing
A.baumannii isolates recovered from two hospitals in Iraq.

Method

Sampling and study design: This cross sectional

study was designed to investigate the characterization
of Carbapenemase –producing A. baumannii isolates
recovered from main hospitals in Babylon province,
Iraq. A total of 540 different clinical specimens (burns,
wounds, urine and blood) were collected from patients
admitted to the out-patient clinics in Hillah Teaching
Hospital and Babylon Teaching Hospital for
Maternity
669 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 669

and Pediatrics at Babylon province, Iraq. These samples (A. pitti, 2 isolates; and A. calcoaceticus, 3 isolates)
were collected during the period between January to depending on the appearance of red colonies on Chrom
June, 2018. Verbal consent was taken from each patient agar, in addition to Vitek 2 system.
before sampling.
Out of 540 clinical samples, only 30 isolates (5.5%)
Isolation and Identification of A. baumannii: All were belonged to A. baumannii. Out of 360 (66.6%)
clinical samples were streaked on MacConkey agar, that showed positive cultures, 35 isolates were belonged
Blood agar and Chrom agar. Isolates were identified to genus Acinetobacter. Only 30 isolates (8.3%) were
to the level of species using biochemical tests (oxidase belonged to A. baumannii (Table 1); out of which 29
and catalase) and Vitek 2 system, in addition to the (96.6%) isolates were obtained from Hillah Teaching
phenotypic characteristics of colonies on Chrom agar (11). Hospital and only one isolate (3.3%) from Babylon
Teaching Hospital for Maternity and Pediatrics.
Determination of antibiotic susceptibility patterns:
Thirty isolates of A. baumannii were selected for
determination of antibiotic susceptibility patterns using Table 1: Distribution of A. baumannii isolates among
modified Kirby-Bauer disc diffusion test (DDT) against different clinical samples
the following antibiotics (CONDA-Spain): Ampicillin Clinical No. (%) No. (%) of A.
(AM), Pipracillin (PRL), Cefepime (FEP), Ceftazidime sample type samples baumannii isolates
(CAZ), Cefotaxime (CTX), Aztreonam (ATM), Burn swab 260 (48.1%) 24 (9.23%)
Imipenem (IMP), Meropenem (MEM), Amikacin (AK),
Wound swab 30 (5.5%) 1 (3.33%)
Gentamicin (CN), Tetracycline (TE), Doxycycline (DO),
Urine 100 (18.5%) 1 (1%)
Ciprofloxacin (CIP), Trimethoprim- Sulphamethoxazole
Blood 150 (27.7%) 4 (%)
(SXT), Colstin (CT), Polymyxin B (PB). Results are
interpreted according to guidelines recommended by Total 540 30 (5.55%)
CLSI guidelines . Determination of MDR and XDR
(12)
Regarding distribution of A. baumannii isolates
among A. baumannii isolates was done according to among different clinical samples, results found that
Magiorakos et al (15). the majority of A. baumannii isolates recovered in this
study was from burn units (24/260; 9.23%), and only 6
Phenotypic detection of Carbapenemases: All
isolates were recovered from other clinical sites. Only
bacterial isolates that resistant to β -lactam antibiotic
one isolate (1%) was detected in urine samples (Table
were tested for β- lactamase production by rapid 1).
iodometric method as described by Forbes et al. (11).
MBL production and Carbapenemase production by Antibiotic Susceptibility of A. baumannii isolates:
MBL E test method was performed as described by The results showed that all A. baumannii isolates
Behra et al. (13), Modified Hodge’s Test (MHT), was (100%) were able to produce β-lactamase using rapid
performed as described by Lee et al. (14) and Modified iodometric method. They also exhibited different pattern
Carba NP test was recommended by CLSI (12). of resistance to different antibiotics (Figure 1). All A.
baumannii isolates (No.=30) demonstrated highest
resistance to penicillins (carbenicillin and ampicillin)
Results (100%), whereas they showed high susceptibility to
Isolation of Acinetobacter baumannii: Results of piperacillin. A low resistance was detected (40%) among
isolates to ceftazidime but they showed relatively high
distribution of different clinical samples showed that
resistance (93.3%) to cefotaxime and cefepime. Results
most samples obtained, were from burns (48.1%) while
also revealed that A. baumannii isolates displayed
other samples distributed among samples of urine,
relatively high resistance rate (73.33%) towards
blood, and wound (Table 1).
imipenem, and meropenem.
A. baumannii were isolated and identified depending Aminoglycosides and quinolones resistance were
on biochemical tests and Vitek 2 system, in addition to, variable among by A.baumannii isolates; (86.6%) to
cultural properties on Chrom agar medium. However, gentamicin and (50%) to amikacin, however, resistance
other species of Acinetobacter were also identified to quinolones (ciprofloxacin) was detected as 20%
as among isolates.
Rates of resistance of our isolates to the rate was 40%. The present study showed relatively low
remaining antibiotics were as follows: 12 (40%) to resistance level to polymyxin B (50%).
each of tetracycline and doxycycline, trimethoprim-
sulfamethoxazole 18 (60%), Polymyxin B 15 (50%), Results revealed that 21 A.baumannii isolates (70%)
and Colistin 18 (60%). For tetracycline, the were found to be multidrug resistant (MDR) and only 9
resistance isolates (30%) were XDR.

Figure 1: Antibiotic resistance pattern of A. baumannii isolates

Carbapenemase Production in A. baumannii: Metallo β-lactamases detection of A.baumannii isolates was

performed by MBL E-test (Imipenem/Imipenem+ EDTA). Results found that 22 isolates out of 30 (73.3%) were
positive to this test (Figure 2).

Figure 2: MBL-producing of A.baumannii isolate. A: A.baumannii BU1: B: A.baumannii BU28

In the modified Hodge’s test, only five isolates of A.baumannii out of 30 (16.6%) displayed a clover leaf like
indentation with imipenem disk indicating a positive result (Figure 3). In Modified Carba NP test, 27 (90%) of A.
baumannii isolates were positive (Figure 4).

Figure 3: Modified Hodge’s test (MHT)

Figure 4: A: yellow color (Reaction tube) of carbapenemase-producing isolates A.baumannii BU1. B: Red
color (control tube). non-carbapenemase-producing isolate A.baumannii BU28.

Only 5 A. baumannii (22.7%) isolates were able to Table 2: Comparison of different methods for
produce the carbapenemase enzyme when detected by detection of carbapenemase producing A. baumannii
MHT and all the remaining isolates were carbapenemase isolates (No. = 30)
negative (Table 2). No. of isolates (%)
Regarding phenotypic detection of MBL using Detection Non-
Carbapenemase
Method carbapenemase
E-test, results found that 22 isolates (%73.3) were Producer
Producer
positive to this test. Comparing the results of this test
MHT* 5 (16.6%) 25 (83.3%)
with MHT, E-test has shown high positivity (73.3%)
when compared to MHT, which showed a low positivity Modified Carba
27 (90%) 3 (10%)
NP test
(22%), due to its false positive results (Table 2).
MBL E test 22 (73.3%) 8 (26.6%)
Carba NP test (CNPt) (CarbAcineto test) *Modified Hodge test
recommended by Nordmann and his colleagues was
also used for detection of MBL A.baumannii producing Discussion
isolates. Results found that 27 isolates of A.baumannii The isolation rate of A. baumannii from different
(90%) were positive to this test. This result makes CNPt clinical specimens was 8.3%. This result was also
is superior to other tests performed (MHT and MBL-E- confirmed by several autors worldwide, who reported
test) that showed a relatively low positivity rate of 22% that the isolation rates of A. baumannii were 7.8%,
and 73.3% respectively (Table 2). 3.7%,
1.5%, and 0.76% respectively (16-19).
The reason for relatively high isolation rate of A. Results of this study against ciprofloxacin was
baumannii compared with the different studies detected as 20% among isolates. Resistance to
mentioned above, may be due to that this study focused quinolones by A.baumannii was also reported by several
on selected samples that are well-known site of authors worldwide. Alsehlawi et al. (22) found that
infections of this bacterium (Table 1). Other reason resistance against ciprofloxacin was (91.6%). Result of
may be attributed to the use of a selective medium for resistance to trimethoprim-sulfamethoxazole was (60%)
isolation of A. baumannii (Chrom agar). it came in dissparallel with study in Turkey by Kulah et
al (26).
Results of distribution of different clinical samples
showed that most samples obtained, were from burns. Based on our findings, the low rate of
This perhaps resulted from ability of A. baumannii carbapenemase enzymes detected by MHT may be due
to survive for long periods of time in the hospital to the fact that although this method is easy to perform,
equipment’s and capacity to acquire drug resistance this but occasional isolates may show false positive results
helps it in the spread of the infection (20). (27)
.
Regarding isolation of A.baumannii from other In previous studies, using modified Hodge’s test,
clinical sites, only one isolate (1%) was detected in several authors reported that 60%, 33.3%, and 53% of
urine samples (Table 1). Nahar, et al. (21) reported A. baumannii isolates, were confirmed as
that carbapenemase producer respectively (19,22). Though
3.1% of these bacteria were isolated from urine samples. CLSI does not advocate the use of MHT for detection of
This result shows that A. baumannii has relatively low Carbapenemase production in non-fermenting gram
prevalence in causing UTI. negative bacilli, several authors have found MHT with
Imipenem,4 EDTA and ZnSO as a useful screening test
Based on our findings, all A. baumannii isolates
for Carbapenemase production (28).
exhibited different pattern of resistance to several
antibiotics. Al-Sehlawi et al. (22) noted that that all A. Regarding phenotypic detection of MBL using
baumannii isolates were resistant to carbenicillin (100%) E-test, and comparing the results of this test with MHT,
but half of them (50%) were resistant to ampicillin- E-test has shown high positivity when compared to
sulbactam. High resistance to this class of antibiotics MHT which showed a low positivity due to its false
may be due to widespread use of these antibiotics in positive results. Previously published data showed that
Iraqi hospitals. E-test to be very sensitive for detection of antimicrobial
The resistance of A. baumannii to cephalosporins in resistance especially for MBLs(13,29). One of the
Iraq was recorded by several researchers AL-Kadhmi (23) advantages of this technique can detect the MBL class
reported that resistance rate of A. baumannii isolates to (by supplemented inhibitor EDTA) and determine the
cefepime, ceftazidime and cefotaxime and were 100%. resistance of organism to the carbepenems (Imipenem)
In Saudi Arabia, the resistance rates of A. baumannii to simultaneously.
Ceftazidime was 91% (24). Detection of MBL A. baumannii producing isolates
Results of this study also revealed that A. by Carba NP test (CNPt) showed high positivity (90%)
baumannii isolates displayed relatively high of detected carbapenemase enzymes. This result makes
resistance rate towards imipenem, and meropenem. this test is superior to other phenotypic assays used (i.e.
The resistance of A.baumannii to Carbapenem was MHT and MBL-E-test).
recorded by several authors in Iraq. Al-Harmoosh (19)
reported that resistance rates of A. baumannii isolates to Conclusion
imipenem, and meropenem were 1% and 47%,
respectively. The carbapenem resistance rates were High isolation rate of carbapenem resistant A.
lower when compared to the rates reported from another baumannii (CRAB) was detected in this study. Most of
medical facility in Kuala Lumpur (25). them were recovered from burn unit. The CNPt assay
was the most reliable among phenotypic assays to detect
Resistance to Aminoglycosides by A.baumannii MBL production.
in this study was also reported by several authors
worldwide (19,22,24). Conflicts of Interest: None of the authors have any
conflicts of interest relevant to what is written.
Source of Funding: University funding was provided 9. Poirel L, Nordmann P. Acinetobacter baumannii–
for: data collection, analysis, and interpretation; trial Basic and Emerging Mechanisms of Resistance.
design; patient recruitment. No public funding was Eur Infect Dis 2008; 2(2):94-97.
received.
10. Karah N, Sundsfjord A, Towner K, et al.
Ethical Clearance: The study was conducted in Insights into the global molecular epidemiology
accordance with the ethical principles that have their of carbapenem non-susceptible clones of
origin in the Declaration of Helsinki. The study protocol Acinetobacter baumannii. Drug Resist Updat
and the subject information and consent form were 2012; 15(4):237-247.
reviewed and approved by a local Ethics Committee. 11. Forbes B, Saham D, Weissfeld A. Bailey and
Scott’s Diagnostic Microbiology. 12th ed., Mosby
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DOI Number: 10.5958/0976-5506.2019.01652.8

The Effect of the Adding Ganoderma Lucidum Fungus Powder

in the Production Performance for the Brown Japanese Quail
Bird

Samawal S. Al-Tikriti1, Abdul Haq Ismail Al-douri1

1
Department of Animal Production, College of Agriculture, University of Tikrit, Iraq

ABSTRACT
This study was conducted in the poultry field belonging to the Department of Animal Production, College
of Agriculture, University of Tikrit for the period from (29/8/2016 to 31/10/2016). The study aimed to
investigate the effect of adding different levels of Ganoderma Lucidum powder in the production and
physiological performance of the Japanese quail bird. It was used 160 birds from Japanese quail bird in the
experiment (40 males and 120 females), with 16 weeks age. The experiment consisted of four treatments,
each treatment contains 10 replicates and in each replicate is four birds (one male and three females). The
birds were distributed randomly to the treatments, treatments were as follows: First treatment T1: a diet
without adding the Ganoderma fungus powder (control). T2: a diet adding to it the Ganoderma fungus
powder with the ratio of (0.5: 1000 g feed). T3: a diet adding to it the Ganoderma fungus powder with the
ratio of (1: 1000 g feed). T4: a diet adding to it the Ganoderma fungus powder with the ratio of (1.5: 1000
g feed). The results showed that the addition of red Ganoderma fungus led to a decrease in the level of feed
consumption for the second and third treatment compared to the control group. There was also a significant
improvement in the feed conversion coefficient for the added treatments compared to the control group. A
significant increase was also occurred in egg production and egg mass for the third treatment (1g/kg feed)
compared to other treatments, while the fourth treatment was excelled in the traits of the average weight of
the egg compared to the rest of the treatments.

Keywords: Ganoderma Lucidum, Productive traits, Japanese quail

bird
Introduction the body of the fungus is called Mycelium. Such these
fungi are Ganoderma Lucidum fungus belonging to the
Fungi are similar to microorganisms, which grow
Polyporaceae family, this fungus has popular names
like plants but without chlorophyll. Fungi depend
such as Mannentake, Holy Mushroom, Ling Chi, Ling
on living organisms or other plants to feed them. The
Zhi Cao. The fungus is commercially cultivated in
available information in literature showed that fungus
China, Japan, Malaysia, and the United States. It grows
was first identified by Greeks in early time and Romans
in Japan on wild plum trees but most of the supplies for
who made them edible, toxic, and medicinal fungi1.
the industry come from agriculture, and the Ganoderma
The fungus is a thallophyte organism that spreads in
fungus is a fungus with meaty texture with a shiny
different environments in wet and dry soil, fresh water,
solid stalk and a cap that resembles a somewhat solid
and in the air, and attacks many organisms, including
umbrella with yellowish color at first, they turn to scarlet
plants, animals, and humans. It has a solid cellular
red and maybe brown. This study was conducted to
wall identifying their shape except for Myxomycetes,
investigate the effect of Ganoderma Lucidum fungus on
which are usually immobile but have moving genital
the productive and physiological traits for the Japanese
cells. Fungi are used in food and medicine. The fungus
quail bird as a laboratory bird2.
is called vegetarian meat, which contains a high
percentage of protein. Some fungi are composed of
monocellular and some of the Multicellular. The fungus Materials and Method
consists of thallophyte, which is not characterized This study was conducted in the poultry farm
by roots, stems, and leaves but is organized into the belonging to the Department of Animal Production,
strings known as Hyphae and Hyphae groups that form College of Agriculture, University of Tikrit for the
676 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 676

period from (29/8/2016 to 31/10/2016). The study Produced Egg Mass: The produced egg mass and the
aimed to investigate the effect of adding different levels percentage of egg production were calculated on the
of Ganoderma Lucidum powder in the production and basis of H.D using the following equations:
physiological performance of the Japanese quail bird.
It was used 160 birds from Japanese quail bird in the The average of Egg mass = an average number of
experiment (40 males and 120 females), with 16 weeks the produced eggs during a given period of time × egg
age. The birds were bred in three-storeyed cages, with weight (g).
dimensions (40 x 40 x 40 cm) for one cage, the number
of cages is 40 cage, where each cage was considered Feed Consumption: The amount of feed consumption
as a replicate. Water was provided by plastic Manhals was calculated by weighing the feed remaining at the
with one Manhal per cage. The feed was provided by end of each week and subtract it from the feed
an external feeder of 150 g feed connected to the cage provided at the beginning of the week to extract the
in such a way as to be easily separated for cleaning daily average of feed consumption for the bird according
and to measure the remaining feed, with the rate of to the following equation:
one feeder per cage. The experiment consisted of four
treatments, each treatment contains 10 replicates and in The daily average of feed consumption (g/bird)
each replicate is four birds (one male and three females).
The birds were distributed randomly on the treatments, F
=
treatments were as follows: First treatment (T1): a diet X 7 L
without adding the Ganoderma fungus powder. T2: a F = feed consumed within a week.
diet adding to it the Ganoderma fungus powder with the L = number of live chicks at the end of the week
ratio of (0.5: 1000 g feed). T3: a diet adding to it the
7 = Number of days of the week.
Ganoderma fungus powder with the ratio of (1: 1000
g feed). T4: a diet adding to it the Ganoderma fungus X = The total number of days in which the
powder with the ratio of (1.5: 1000 g feed). mortality
chicks were fed.
Chemical Analysis of Ganoderma fungus Powder:
The chemical analysis for the Ganoderma fungus of Food Conversion Coefficient: The food conversion
DXN Malaysia Company was used to estimate the coefficient necessary to produce one gram of eggs was
amount of energy, protein, carbohydrate, fat and calculated according to the following equation:
dietary fiber per Food conversion coefficient (g feed/g egg) = The
100 g as shown in Table (2).
daily average of feed consumption/the average of the
produced egg mass (g/day).
Table 1: Chemical analysis for the Ganoderma
fungus powder per 100 g. Experimental data were analyzed using a completely
randomized design (CRD) to study the effect of studied
Material Amount treatments on different traits. The significant differences
Energy 348 kcal between averages were compared using the Duncan
Protein 4.0 g Multiple Range Test3, and The Statistical Analysis
Carbohydrates 86.0 g Software (SAS) was used in the statistical analysis4.
Fats 2.7 g
Dietary Fiber 0.9 g Results and Discussion

The Studied Traits: Table (2) shows the average weight of the egg, it
was noted a significant superiority of T4 on T3, while
Egg Production: The eggs were collected at 9 am every no significant differences between T4, T1 and T2. There
day throughout the breeding period (9 weeks) and the were no significant differences between T1 and T4 with
average of total egg production was calculated during
T3, The averages weights of egg amounted to
the period of the experiment.
(11.83,
Egg Weight: Egg weighed daily individually for each 11.45, 11.02, 12.03 g), respectively, while the traits of
replicate using a sensitive balance (Citizrn type, Fr- the egg production during the experiment period (60
H1200 Model), with accurately 0.01 (two digits after the days), T3 was excelled and showed significant
point).
677 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 677
differences with T1 and T2, while no significant
difference was shown
with T4. There were no significant differences between because this reporter regulates or mediates the work
T1, T2 and T4, the egg production amounted to (46.07, of many peptide hormones that cannot penetrate the
47.16, 51.87, 48.83 eggs/birds) respectively, and the target cell wall but are associated with the receptors on
percentage of production on the basis HD amounted the cell membrane and the complex hormone receptor,
to (76.77, 78.61, 86.44, 81.38%), respectively. As which indirectly activates an enzyme called Adenylate
for the trait of the daily egg mass, the second and Cyclase, which converts the partial energy (ATP)
third treatments were significantly excelled on the Adenosine try phosphate to the CAMP inside the cell
first treatment. No significant differences were found and this acts as a second reporter by indirectly activating
between them. No significant differences were observed other enzymes and proteins within the target cell, In
with the fourth treatment. No significant difference was the middle of which the work of several hormones,
observed between the first treatment and the fourth including the Luteinizing hormone (LH) and Follicle-
treatment. The results of the third treatment were agreed stimulating hormone (FSH)8. The release of these two
with5,6 in his study on the Japanese quail bird, where hormones led to stimulating the ovary and increases
showed that the egg weight of the Japanese quail bird its activity in the formation of eggs and increasing egg
amounted to (11.00 g) while its results did not match production because of a positive correlation between
the results of the first, second and fourth treatments. The the concentration of these hormones in blood plasma
results of the experiment did not agree with the results and egg production9. The regularity of secretion of LH
of in their study on the Japanese quail bird7, where they hormone leads to the regularity of progesterone
found that the percentage of average egg production secretion from Granulosa Cells for mature follicles,
amounted to 68.97%. The reason for the improvement in leading to increased secretion of LH by positive
the percentage of average eggs production on the basis feedback at the hypothalamus level, thereby increasing
of (HD) in the adding treatments for the Ganoderma LH secretion, increasing ovulation, and increasing egg
fungus, where some of the materials directly affect the production10. Which lead to increasing the progesterone
production and synthesis of Prostaglandins, the main production, which is a precursor to estrogen, is
material in its synthesis is the Arachidonic acid and important for the synthesis of the vitellogenin precursors
other essential fatty acids, the survival it in the and lipoproteins, and increasing the speed of
circulatory system and the Prostaglandins work to transmission to the ovary, faster vesicle growth, and
stimulate and increase the ovulation9.
manufacture the adenosine monophosphate (CAMP),

Table 2: Effect of adding the Ganoderma fungus powder to the diet on the productive traits for the eggs of
the Japanese quail

Productive traits T1 T2 T3 T4
Egg weight (g) 11.83 ± 0.14 ab 11.45 ± 0.25 ab 11.02 ± 0.12 b 12.03 ± 0.17 a
Number of produced eggs (egg/bird) 46.07 ± 1.56 b 47.16 ± 0.31 b 51.87 ± 1.01 a 48.83 ± 0.29 ab
percentage of egg production (HD)% 76.77 ± 1.01 b 78.61 ± 1.05 b 86.44 ± 1.82 a 81.38 ± 1.12 ab
Eggs mass 9.63 ± 0.12 b 9.86 ± 0.09 a 9.83 ± 0.14 a 9.79 ± 0.08 ab
a,b in the row means significant differences at level (p <0.05).
Table (3) indicates that the adding of Ganoderma third treatments in the sixth week, while the first, second
fungus powder to the diet at different levels indicates and third treatments were significantly excelled on the
no significant differences between the first, second, fourth treatment in the seventh week. A significant
third and fifth weeks from the breeding period. The difference was shown for the third treatment compared
results showed a significant difference in the first to the second treatment, while did not record significant
treatment with the second, third and fourth treatments. differences between the third treatment and the first and
The first treatment recorded the highest amount of fourth treatments in the eighth week. The final results
feed consumption amounted to (29.14 g/bird/day). The of the breeding period showed a significant difference
results also showed significant differences between the between the first treatment and the second and third
first and fourth treatments compared to the second treatments, while no significant difference was recorded
and
with the fourth treatment. where the first treatment contain red Ganoderma fungus many active substances
recorded the highest percentage for feed consumption with more than 200 active substances, including organic
between the first treatment and the second and third germanium, Ergesterois, adenosyl, and polysaccharides,
treatments, while no significant difference was recorded as well as containing it Ganoderic acids and triglycerides
with the fourth treatment where the first treatment contained in the bright red cap components for the
recorded the highest percentage for the feed fungus, These substances are beneficial for
consumption between the treatments amounted to (28.76 cardiovascular, liver health. They also promote
g/bird/day), where indicated that the percentage of feed metabolism, inhibit tissue degradation, and make
consumption for Japanese quail bird amounted to (24.40 maximum use of nutrients and their metabolism for use
g/bird/day), and did not agree with10 found that the in egg production. also indicated to that the chemical
percentage of feed consumption for the Japanese quail composition of the fungus contains a significant amount
birds amounted to (35.71 g/bird/day). The reason for of crude protein, carbohydrates, raw fiber, raw fat, and
the low feed consumption adding treatments low fatty acids, making it a valuable food component
compared to control to for use in poultry production11.
Table 3: Effect of adding the Ganoderma fungus powder to the diet on the percentage of feed consumption
(g) and the feed conversion coefficient for the Japanese quail bird.
Period (week) T1 T2 T3 T4
1–2 24.82 ± 0.31 24.39 ± 0.53 24.39 ± 0.59 25.12 ± 0.31
2–3 26.51 ± 0.33 26.19 ± 0.59 26.36 ± 0.39 26.50 ± 0.34
3–4 28.11 ± 0.31 27.10 ± 0.67 25.46 ± 2.26 27.98 ± 0.48
4–5 29.14 ± 0.54 a 27.46 ± 0.49 b 27.60 ± 0.39 b 27.76 ± 0.33 b
5–6 31.53 ± 0.42 30.64 ± 0.67 30.64 ± 0.34 31.46 ± 0.36
6–7 28.44 ± 0.44 a 24.89 ± 0.85 b 25.86 ± 0.51 b 28.35 ± 0.61 a
7–8 31.12 ± 0.31 a 30.96 ± 0.56 a 31.86 ± 0.50 a 28.55 ± 0.60 b
8–9 30.41 ± 0.45 ab 28.81 ± 0.37 b 30.69 ± 0.89 a 29.74 ± 0.55 ab
1–9 28.76 ± 0.15 a 27.55 ± 0.35 b 27.86 ± 0.33 b 28.18 ± 0.20 ab
feed conversion coefficient 3.01 ± 0.09 a 2.92 ± 0.11 ab 2.77 ± 0.03 b 2.82 ± 0.14 b
a,b in the row means significant differences at level (p <0.05).
Table (4) shows that there was a significant Conclusion
difference between T1 with T3 and T4 in the feed
conversion coefficient. There was no significant We consoled from this search that the addition
difference between T1 and T2. The results did not show of red Ganoderma fungus led to a decrease in the
significant differences between T3 and T4 with T2, level of feed consumption for the second and third
the averages of feed conversion coefficient amounted treatment compared to the control group. There was
to (3.01, 2.92, also a significant improvement in the feed conversion
2.77, 2.82 g fed/g egg), respectively. The results of T3
coefficient for the added treatments compared to the
were agreed with in his study on the Japanese quail
control group. A significant increase was also occurred
bird, where the feed conversion coefficient amounted to
(2.79 g fed/g eggs), while the results of the rest of the in egg production and egg mass for the third treatment
treatments did not agree with him. The improvement in (1 g/kg feed) compared to other treatments, while the
the feed conversion coefficient and the increase in egg fourth treatment was excelled in the traits of the average
production lead to an increase in the mass of produced weight of the egg compared to the rest of the treatments.
eggs compared to the number of feed grams. The reason
is due to the fact that Ganoderma fungus contains many Conflict of Interest: None
important nutrient elements and enzymes that increase
Source of Funding: Self
nutrient elements availability within the digestive tract
and thus increase the benefit of Feed consumption and Ethical Clearance: Not required.
turn it into eggs12.
REFERENCES Fatty Acid Supplemented Diets on Semen Quality
1. Zakhary JW, Taiseer M, Abo-Bakr A, EL-Mahdy in Japanese quail (Coturnix coturnix japonica).
AR, El-Tabey SAM. The chemical composition International Journal of Poultry Science. 2010. 9
of wild mushrooms collected from Alexandria, (7): 656-663.
Egypt. Food Chemistry. 1983. 11(1): 31-41. 8. Al-Hassani Diaa Hassan. Poultry bird physiology.
2. NRC, National Research Council. Nutrient Baghdad, Dar Al-kutub for Printing and
requirements of Poultry,9th ed.National Academy Publishing. College of Agriculture, University of
press, Washington, D.C. 1994. Baghdad. 2000.

3. Duncan DB. Multiple range and multiple F-test- 9. Sturkie PD. Avian physiology. Itheca, New York:
Biometrics. 1955, 11:1-42. comstock publishing associates. 1986.

4. SAS. SAS/STAT User’s Guide: Statistics Version 10. Novero RP, Beck MM, Gleaves EW, Johnson AL,
6.12 Edition. SAS. Institute Inc., Cary, NC. The Deshazer JA. Plasma progesterone, luteinizing
USA. 2001. hormone concentrations, and granulosa cell
responsiveness in heat-stressed hens1,2. Poultry.
5. Latif Osama Ahmed. Effect of Addition Science. 1991. 70(11):2335-2339.
Different Levels of Ginger Oil in the Diet on
some Productivity Traits and Quality of Quail’s 11. Ogbe AO, Obeka AD. Proximate, Mineral and
Coturnix japonica Temminck & Schlegel, 1849 AntiNutrient Composition of Wild Ganoderma
Eggs. Basra Journal of Agricultural Sciences, lucidum: Implication on It Utilization in Poultry
2016. 29 (2): 107-118. Production, Department of Animal Science,
Faculty of Agriculture, Nasarawa State
6. Al-Tikriti Samawal Saadi Abdullah. The Effect University, Keffi, Nigeria. 2013.
Of Divergent Selection For Body Weight on Egg
Quality Traits In Japanese Quail Brown. Tikrit 12. Kalsum U, Soetanto H, Achmanu A, Sjofjan O.
University Journal of Agricultural Sciences, 2016. Influence of a probiotic containing lactobacillus
16 (2): 121-127. fermentum on the laying performance and egg
quality of Japanese Quails. International Journal
7. Al-Daraji HJ, Al-Mashadani HA, Al-Hayani WK, of Poultry Science. 2012. 11(4): 311-315.
Al-Hassani AS, Mirza HA. Effect of n-3 and n-6
DOI Number: 10.5958/0976-5506.2019.01653.X

Effect of Non-pharmacological pain Management Methods on

Reduction the Severity of Labor Pain in Primigravida Women
at AL-Elwyia Maternity Teaching Hospital

Sarab Nasr Fadhil1, Rabea Mohsen Ali2

1
Assist. Instructor, 2Professor, Maternal and Neonate Nursing
Department, College of Nursing, University of Baghdad

Abstract
Objectives: To evaluate the effect of non-pharmacological practices on reducing level of pain between
study
groups during labor.
Methodology: A quasi-experimental study conducted on non-probability of (60) women (30) control and
(30) study group whom admitted to Al-Elwyia Maternity Teaching Hospital suffering from labor pain for
the period of (4th July 2018 through 24th October 2018). Descriptive& Inferential statistical analyses were
used to analyze the data.
Results: The highest percentages of both groups were in age group (< 20) years, primary schools graduates,
housewife, from “urban area”, within low category of socioeconomic, at gestational age between (39 – 40
weeks +6day. With highly significant differences concerning reducing the severity of pain in (1st, 2nd, and 3rd)
stages of labor among study and controlled groups at (P=0.000), (P=0.000), &( at (P=0.002) respectively.
Conclusions: The study concluded that are a highly significant differences concerning reducing level of
pain
in (1st, 2nd, & 3rd) stages of labor between study and control groups.
Recommendations: Need to develop training program to all midwives working in delivery room to
upgrade their knowledge and skills about importance of using non-pharmacological methods to help them
perform their role effectively in reducing level of pain for women during labor.

Keywords: Effect, Non-Pharmacological, Labor Pain, Management, Primigravida.

Introduction Methodology
The intensity of the pain experienced during labor A quasi-experimental study design was conducted on
is considered to be one of the most painful experiences purposive sample, of (60) women (30) control group and
in life. It is mainly dependent on stages of labor. At (30) study group whom admitted to Al-Elwyia Maternity
the onset of labor (in first stage) the pain is related to Teaching Hospital suffering from labor pain. Study
continuous contractions of the uterine muscle, dilation implemented for the period of (4th July 2018 through
of the cervix, stretching of the perineal tissue and 24th October 2018). Data collection will be gathered by
pelvic floor muscle, while at the second stage of labor application one of non-pharmacological strategies of
pain relief methods include: ( frankincense, jasmine,&
the descent of fetus presenting part, fetus position, and
olive oils), massage,body movement and change position
pressure on bladder, bowel and the pelvic structure lead
(squatting, side-lying,& standing),breathing technique,
to intensify the pain. Also fear of birth process, anxiety,
and therapeutic touch),and by used questionnaire format
sense of control loss and stress all affecting on women’s which consisted of four parts, including demographic,
childbirth experiences and their perception towards reproductive characteristics, non-pharmacological
labor. Therefore, the first priority in confirm a positive methods the delivering woman received during labor and
labor outcome and satisfying the physiological need of FLACC behavior scale to measure intensity of pain level.
women is by effective labor pain management (1). A pilot study was carried out between the 25th June
2018,
681 Indian Journal of Public Health Research
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 681

to 1st July 2018, on (10) women to determine the out through the 12 experts. Descriptive and inferential
reliability statistical analyses were used to analyze the data.
of the questionnaire and content validity was carried

Results

Table 1: Distribution of the Socio-demographic Characteristics for the studied Sample with Comparisons
Significant
Study (n = 30) Control (n = 30) C.S. (*)
Variables Groups
No. % No. % P-value
< 20 14 46.7 16 53.3
20 _ 24 10 33.3 11 36.7 C.C. = 0.224
Age Groups
25 _ 29 3 10 3 10 P = 0.365
(Per Years)
30 _ 34 3 10 0 0 (NS)
Total 30 100 30 100
Illiterate 2 6.7 0 0
Read &write 2 6.7 3 10
Primary school 9 30 11 36.7
Intermittent school 6 20 10 33.3 C.C. = 0.291
Educational
P = 0.476
level for wife Preparatory school 4 13.3 3 10 (NS)
Baccalaureate 6 20 3 10
Higher studies 1 3.3 0 0
Total 30 100 30 100
Housewife 28 93.3 28 93.3
Employee 1 3.3 0 0 C.C. = 0.147
Occupation
P = 0.513
status of wife Others 1 3.3 2 6.7 (NS)
Total 30 100 30 100
Urban 27 90 26 86.7 C.C. = 0.052
Residential
Suburban 3 10 4 13.3 P = 0.688
environment
Total 30 100 30 100 (NS)
(*)
NS: Non Sig. at P>0.05; Testing based on a contingency coefficient (C.C.) test.

Table (1) shows that the highest percentage (46.7%), (53.3%) respectively for both study and control groups
were in age group (< 20) years old, (30%) (36.7%) respectively in study and control groups were at (primary
school), (93.3%) in both groups were housewife, (90%) (86.7%) respectively were from urban area.

Table 2: Distribution of the Reproductive Characteristics for the Studied Sample with Comparisons Significant
Study (n = 30) Control (n = 30) C.S. (*)
Variables Classes
No. % No. % P-value
37- 38 + 6day 12 40 11 36.7
39- 40 + 6day 16 53.3 17 56.7 C.C. = 0.035
Gestational Age
P = 0.964
(per weeks) 41 & more 2 6.7 2 6.7 (NS)
Total 30 100 30 100
Ruptured 14 46.7 10 33.3 C.C. = 0.135
Membrane
Intact 16 53.3 20 66.7 P = 0.292
Status
Total 30 100 30 100 (NS)
(*)
NS: Non Sig. at P>0.05; Testing based on a contingency coefficient (C.C.) test.
Table (2) shows that the highest percentage (53.5%) (56.7%) respectively for both study and control groups
were at gestational age between (39 weeks – 40 weeks +6day), and (53.3%) (66.7%) respectively for study and control
groups have intact membrane status.

Table 3: Type of Practices Concerning Pain Management Methods Uses for Study group
Yes No
No. Items No. F % F % Order
1. Frankincense Oil 30 9 30.0% 21 70.0% 1.0
2. Jasmine Oil 30 7 23.3% 23 76.7% 2.0
3. Side-Lying Position &Breathing 30 4 13.3% 26 86.7% 3.0
4. Squatting Position 30 4 13.3% 26 86.7% 3.0
5. Massage 30 1 3.3% 29 96.7% 4.0
6. Massage &Standing position 30 1 3.3% 29 96.7% 4.0
7. Therapeutic Touch &standing 30 1 3.3% 29 96.7% 4.0
8. Olive Oil 30 1 3.3% 29 96.7% 4.0
9. Breathing Technique 30 1 3.3% 29 96.7% 4.0
10. Therapeutic Touch & side-lying position 30 1 3.3% 29 96.7% 4.0

Table (3) results show that “ Frankincense Oil” method has recorded the high and first ordered method, and
accounted 9 (30%), then followed with Jasmine Oil” method, and accounted 7 (23.3%), then followed with
“Squatting Position, and Side-Lying Position &Breathing” methods, and accounted 4 (13.3%), Massage, Massage&
Standing position, Therapeutic touch & Standing, Olive oil, breathing technique, & side lying position accounted
1(3.3%).

Table 4: Distribution of Pain Assessment in different Stages between studied groups using (FLACC
behavioral scale) with Comparisons Significant
Stages of FLACC behavioral No Groups C.S. (*)
. and % Total
labor scale category Study Control P-value
No. 0 0 0
Mild
% 0.00% 0.00% 0.00%
No. 30 2 32
Moderate C.C. = 0.647
% 100% 6.7% 53.3%
1st Stage P = 0.000
No. 0 28 28
Sever (HS)
% 0.00% 93.3% 46.7%
No. 30 30 60
Total
% 100% 100% 100%
No. 0 0 0
Mild
% 0.00% 0.00% 0.00%
No. 29 0 29
Moderate C.C. = 0.695
% 96.7% 0.00% 48.3%
2nd Stage P = 0.000
No. 1 30 31
Sever (HS)
% 3.3% 100% 51.7%
No. 30 30 60
Total
% 100% 100% 100%
No. 30 20 50
Mild
% 100% 66.7% 83.3%
No. 0 6 6
Moderate C.C. = 0.408
% 0.00% 20.0% 10.0%
3 Stage
rd
No. 0 4 4 P = 0.002
Sever % 0.00% 13.3% 6.7% (HS)
No. 30 30 60
Total
% 100% 100% 100%
(*)
HS: Highly Sig. at P<0.01; NS: Non Sig. at P>0.05; Testing based on a contingency coefficient (C.C.) test.
Table (4) results show that concerning 1st & 2nd and gestational age though essential parts of labor,
stages the pain intensity level have recorded a are major contributors to labor pain(2). the highest
moderate level in the study group, while sever level in percentages (53.3%) (66.7%) respectively for both study
controlled, then followed in the 3 rd stage, all study cases and control groups have intact membrane status. These
30(100%) has recorded mild level, while only group of women artificial rupture of membrane were
20(66.7%) in controlled group has recorded mild done for them to enhance progress of labor and increase
level, and the leftover has recorded moderate and cervical dilation,and this mean the women exposed to
sever, and they are accounted more painful than those with spontaneous rupture of
6(20.0%), and 4(13.7%) respectively. membrane at term, and need to arrange for educating
them about how copy with pain
Discussion
Non Pharmacological Methods: The results of table
Regarding to Socio Demographic Characteristic: (3) show that “ frankincense oil” method has recorded
(Table 1) The results show that the highest percentages the highest and accounted 9 (30%), then followed
(46.7%), (53.3%) respectively for both study and control with jasmine oil” method, and accounted 7 (23.3%),
groups are (< 20) years old. This finding is in agreement then followed with “squatting position, and side-lying
with a retrospective study which found that out of the position &breathing” methods, and accounted 4
(60) sample of primigravida women, the highest age (13.3%), finally, massage, massage and standing
groups were between (18-22) years that was (41.7%) position, therapeutic touch and standing, olive oil,
and the lowest were found in the age group of (30-34) breathing technique, and therapeutic touch and
and they are accounted (11.7%) (2).The highest distraction’’ are accounted 1 (3.3%). In this study
percentages (30%) (36.7%) respectively for both study noted that essential oils (Frankincense, jasmine, and
and control groups are primary schools graduates. This olive) recorded the high number of uses and accounted
finding is in agreement with study that finds that the 17(56.7%), because its promoting general relaxation,
women with low educational level will have minimum reduce anxiety and helpful to reduce labor pain, Then as
level of performance to cope with pain during childbirth observed in this study some women prefer changing
process. While it was pointing that woman with positions which include squatting that accounted
higher level of educational 4(13.3%) and side- lying position and standing
‘’such as college’’ was more perception to the childbirth which used as combine with other method. These
preparation methods, presenting classes, and books positions help to speed labor by adding the benefits of
reads to cope with labor pain (3). The height significances gravidity and changing the shape of the pelvis in
in occupational status of wife, are “Housewives”, and addition the position that women assumes have a
they are accounted (93.3%) in both study and control profound effect on uterine activity and efficiency
groups, this finding is constant with the study that found (5)
.Related to use breathing technique in this study one
unemployed women will have more free time in order woman chose to apply breathing technique as alone be
to read book s, watch videos, and attend classes. Which sit in bed and 4 of them use breathing technique with
all lead to a more positive childbirth experience (4). The slid lying position and they are accounted 4(13.3) the
vast majority (90%) (86.7%) respectively of the both researcher teaches woman how to apply this method
study and control groups were living at urban areas the based on evidence-based studies(6-8). Relative to use of
researcher noted that although these women living in massage technique the results show that there are two
urban area and were have sufficient awareness that labor
women were choosing massage (one massage combined
is painful, but there is lack of knowledge regarding the
with standing position and other with side-lying
methods of non-pharmacological pain relief, and there
position). The massage is one of the best non
advantages and disadvantages.
pharmacological therapies useful in labor. Because it has
Reproductive Parameters: Table (2) Results show that the potential benefits such as decreasing the intensity of
the highest percentage (53.5%) (56.7%) respectively for pain. Relative to use therapeutic touch observed that
both study and control groups were at gestational age there are two women chose therapeutic touch but in
between (39 weeks – 40 weeks +6day), these result are different way one therapeutic touch with standing
agreement with study that found that physiological position and another one use therapeutic touch with side-
factors such as uterine contractions, cervical dilation, lying position.
Pain Assessment in Different Stages between Studied jasmine oil massage, it is evident that the jasmine oil
Groups Using (FLACC Behavioral Scale): In present was effective in reducing level of first stage labor pain
study the researcher used FLACC behavior scale to among primigravida women (13). Furthermore, the use of
measure the intensity of labor pain because the labor touch therapy helps women maintain their sense of body
pain affects a woman’s emotional control and it can be integrity and increases the ability to their compatibility
associated with fear that leads to a prolonged childbirth with the delivery (14).
process and so mother are request for an unnecessary
cesarean section(9). In addition to that the intense and Conclusions
prolonged uncontrolled labor pain can cause long-term
excitement imbalance and can psychologically disturb The study concluded that there are a highly
mother’s health.(10),So that the researcher application significant differences concerning reducing level of
some methods of non-pharmacological pain relief and pain in (1st, 2nd, & 3rd) stages of labor between study and
reassess the pain level for study group, it was found control groups.
that there are high significant at level of pain in two
groups and in all labor stage as shown in table (4) show Conflict of Interest: Nil
that concerning 1st & 2nd stages the pain intensity level
Source of Funding: Self
have recorded a moderate level in the study group,
while sever level in controlled, then in the 3 rd stage, all Ethical Clearance: Obtained from the
study cases 30(100%) has recorded mild level, while
z Ministry of Health/Al-Russafa Health Directorate
only 20(66.7%) in controlled group has recorded mild
level, and the leftover have recorded moderate and z Ministry of Planning and Development
sever, and they are accounted 6(20.0%), and 4(13.7%) Cooperation/ Central Statistical Organization
respectively. These findings are in agreement with study Technique and Information.
which measures the effects of breathing exercises on z Al-Elwyia maternity teaching hospital.
maternal pain during the second stage of labor revealed
that the mean visual analog scale score of intervention z All laboring women participants in the research
group and control group were (88.2 ± 6.3) and -have been approved before the questionnaire is
(90.5 started.
± 7.0), respectively (P < 0.001). Based on this study,
breathing exercises for women are effective in reducing Recommendations
the perception of labor pain, therefore the breathing
exercises consider an effective method for labor pain The study recommended developing training
management and lessening the duration of labor (7). program to all midwives working in delivery room to
Another study which revealed that the primiparous upgrade their knowledge and skills about importance of
women distributed in to two groups the (experimental using non-pharmacological pain management methods
and the control) group. Where the experimental group to help them perform their role effectively in reducing
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DOI Number: 10.5958/0976-5506.2019.01654.1

Cholera Outbreak in Iraq, 2017

Shakir Mohsen Zgheir1, Nabil Mansur Mustafa1, Ali Abdalkader Ali1, Jawad Al-Diwan2
Communicable Diseases Control Centre, Iraq, Minstry of Health, 2MBChB, MSc, FIBMS/FFPH,
1

Department of Community & amp; Family Medicine, College of Medicine, University of Baghdad

ABSTRACT
Background: In Aug, 2017, Iraq as one of the Eastern Mediterranean Region countries experienced
cholera outbreak. Iraq is a cholera endemic country with epidemics every 3-4 years. Poor services due to
the wars and conflicts, the influx of internally displaced people reinforce many outbreaks in the last 10
years.
Aim of the study: To assess the Cholera Outbreak in Iraq, 2017
Method: We defined a case of Cholera as a patient with diarrhea that had a positive stool sample for vibrio
cholera. Epidemiological investigations were carried for each case and their contacts was examined also the
type of drinking water was determined.
Results: The total suspected cholera cases were 505. Most of the cases (98%) were inaba with a peak in
W47 giving a case fatality rate of 0.6%. Generally, the diarrheal cases were in the middle and south of Iraq
and the proportion of cholera cases was higher in those who use river, vehicle and other sources of water
while most of cases occurred in autumn.
Conclusions: Provision of adequate and safe water supply besides other control measures should be in
place to prevent further outbreaks. Epidemiological and laboratory evidence suggested that the water was
the source of this outbreak.

Keywords: Cholera, Iraq 2017, epidemics, water, endemic

countries

Introduction water and sanitation is important in control of

cholera
Cholera is an infectious disease caused by ingestion transmission and other waterborne diseases (2).
of bacterium Vibrio cholerae with contaminated food or
drinking water (1). Only two serogroups (O1 and O139) In the Eastern Mediterranean Region, many
cause outbreaks among many serogroups of V. cholerae. outbreaks of cholera were reported from Afghanistan,
V. cholerae O1 has caused all recent outbreaks and the Djibouti, Iraq, Pakistan, Sudan, Somalia and Yemen in
world now under the seventh pandemic, which started the last decade .
(3)

since 1961 in South Asia (2). Cholera is endemic in Iraq(4) and it was reported in
1820 for the first time in Basrah (5). Iraq faced several
The disease is endemic in many countries and the
epidemics during the last 5 decades all together due to
discrepancy in the estimated burden of the disease may
underdevelopment and damage of infrastructures as a
be related to the fact that many cases are not recorded
result of wars and conflicts. Shortage in provision of safe
due to weak surveillance systems, weak records and fear water in addition to bad sweage system, reinforce many
of impact on trade and tourism. The provision of outbreaks in the last ten years (6)(7).
safe
Publishing on cholera epidemics in Iraq is scarce,
therefore this report was carried out to highlight this
Coresponding Authour:
problem, also to elucidate the picture of the epidemic
Dr.Ali Abdalkader Ali
and the factors potentiate the occurrence of the disease.
Communicable Diseases Control Centre, Iraq,
Minstry of Health Aim of the study: To assess the Cholera Outbreak in
Email: [email protected] Iraq, 2017
687 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 687

Material and Method Results

Data were collected from communicable diseases In year 2017, the first laboratory confirmed sporadic
center (Minisry of Health) for the year 2017. Cholera case of cholera was female 37 years old, lives in Baghdad
case was defined according to WHO definition (8). Al Resafa/Al Kamaliya District which diagnosed in W22/
May. Then cases continued through Augest to December
Laboratory Tests and Confirmation: Stool samples
by a gradual occurrence of cases that progressed to an
were collected in primary health care centres (PHCCs)
outbreak to register 505 (36.9%) cholera cases which
and hospitals positive for V. Cholera is transferred to
confirmed by Central Public Health Laboratory/Iraq
the Reference Laboratory at the Central Public Health
(CPHL) out of 1367 suspected cases. Most of the
Laboratory for confirmation. Each case was visited and
cases,
interviewed by a team, their contacts were examined.
497(98.4%) caused by V. cholerae O1, El Tor, Inaba
Epidemiological investigation was carried out for each
serotype while the remaining cases caused by V. cholerae
case (home visit for interview, examination of contact,
O1, El Tor, Ogawa serotype, 8(1.58%). The peak was
type of water used and personal data).
demonstrated at W47 (114 cases)(Figure 1).

Figure 1: Epi-curve of cholera cases by international weeks

The overall rate was 1.33/100000 population and Table 1: Distribution of cholera cases by
3 patients with cholera died giving a case fatality gender, Iraq, 2017
rate
0.6%. Out of 505 cases, 254 were male (37.3%) giving Variable Suspected Positive
male to female ratio 1.01:1. Total (N = 1367) Confirmed (n = 505)
Gender
No. (%) No. (%)
The mean age was 31.5 ± 19.95 years old and
ranged Male 681 (49.82) 254 (37.3)
from 2 months to 90 years old. Female 686 (50.18) 251 (36.59)
χ²=0.074 , d.f =1, P-value = 0.786
Although the proportion of suspected cholera cases
among females was higher than males [686 (50.18%) The suspected cholera cases were distributed
over
vs. 681(49.82%)], however, it showed no significant
association between sex and cholera infection (χ²=0.074, 11 governorates out of 18 in Iraq. The higher number of
P=0.786). (Table 1) diarrheal cases was in Baghdad Resafa and the
lowest
was in Missan [706 (51.64) vs. 10 (0.37%)]. The highest Conted…
proportion of cholera cases among diarrheal cases were
in Kerbala while the lowest in Najaf as [66(98.51%) vs. Tab water &
831 (60.79) 350 (42.13)
R.O.
2 (5.88%)] respectively, whereas other governorates
showed a percentage ranged between (10% to 67%), Others
(river and
giving a significant association between cholera 14 (1.02) 9 (64.29)
vehicle
infection and governorate (P=0.000). (Table 2) water)
χ²=32.8, d.f =3,P-value = 0.000
Table 2: Distribution of cholera cases by
governorates, Iraq, 2017 The highest proportion of cholera infection among
diarrheal cases were in May while the lowest in July [2
Variable Suspected Positive
(100%) vs. 0 (0.0%)] respectively, on the other hand the
Health Total (N = 1367) Confirmed (n = 505) second highest percentage of infections among diarrheal
Directorate No. (%) No. (%)
cases was in September (64.18%). A significant
Baghdad association was found between the cholera occurrence
706 (51.64) 265 (37.54)
Resafa
and seasons as shown in Table 4 (P=0.000).
Kerbala 67 (4.90) 66 (98.51)
Diwaniya 187 (13.68) 54 (26.88)
Table 4: Distribution of cholera cases by months,
Babylon 207 (15.14) 59 (28.5)
Iraq, 2017
Wassit 50 (3.65) 25 (50)
Missan 10 (0.73) 4 (40) Variable Suspected Positive
Kirkuk 15 (1.09) 3 (25) Total (N = 1367) Confirmed (n = 505)
Month
No. (%) No. (%)
Nineveh 47 (3.43) 5 (10.64)
May 2 (0.146) 2 (100)
Najaf 34 (2.48) 2 (5.88)
June 12 (0.88) 5 (41.67)
Baghdad
14 (1.02) 2 (14.29) July 1 (0.08) 0 (0)
kerkh
Muthana 30 (2.19) 20 (66.67) August 6 (0.44) 1 (16.67)
September 67 (4.9) 43 (64.18)
χ²=168.9,d.f =10,P-value = 0.000
Similarly, suspected cholera cases showed a October 364 (26.63) 119 (32.69)
significant association with the source of water being November 838 (61.3) 316 (37.71)
used along the study period (χ²=32.8, P=0.000). As the December 77 (5.63) 19 (24.68)
χ²= 34.5, d.f = 7,P- value = 0.000
highest proportion of suspected cases were found among
those who used tab water and R.O, 60.79%(831). On
the other, the proportion of cholera cases was higher Discussion
among diarrheal cases that use the river, vehicle and
The index case was diagnosed in W36/29August
other sources of water while the lowest in those used
in Baghdad Risafa/Al Kamalea which followed by
R.O water [9 (64.29%) vs. 60 (25.97%)] respectively, as
several cases from multiple governorates as an outbreak
shown in Table 3.
continued to W51/17December with total number cases
505. In 2007 outbreak, the total number of cholera cases
Table 3: Distribution of cholera cases by source of were 4659 and most of cases were occurred in the north
water, Iraq, 2017 of Iraq while in the current study the number cases were
Variable Suspected Positive 505 and most of them were occurred in the middle and
Source of Total (N = 1367) Confirmed (n = 505) south of the country this is because the outbreak may
water No. (%) No. (%) occur every 3 to 5 years (4).
Tab water 291 (21.29) 86 (29.55) The first case in 2007 an outbreak was
R.O. 231 (16.9) 60 (25.97) diagnosed
in Baghdad on W38/19 September in a study conducted
by Khwaif et al (2010) (5), alternatively in the current Also in the present study the highest percentage
outbreak the first cholera case was diagnosed in of suspected cholera cases was in age group 16-45
Baghdad at the end of August 2017, whereas in 2015 the years 47.18% (645), which correspond to the results of
first case was diagnosed in Diwania/Gamas in study conducted in Mexico (2012) showed similar age
September (9). distribution in which the greatest proportion of cholera
In this epidemic the serotypes were Inaba and in age group 25-44 years and those aged more than 65
Ogawa. In 2016 outbreak in which only 3 cases of Inaba years which interpreted to occupational exposure and
were diagnosed, as well as in 2007, also Inaba was eating habit (19).
reported (5). In Iraq two serotypes in which Inaba was
Not all areas of Iraq served by tab water network,
dominant followed by ogawa,this confirmed by a study
especially the remote and rural areas in which the people
conducted by Saleh et al (2011) on 80 clinical samples
depend on rivers, streams and estuaries for domestic
from diarrheal patients in Iraq during the period 2007-
2009 to explore bacterial isolates (10). use and may be for drinking or served by vehicle water.
There may be shortage in water provision and use
In the current epidemic the rate of cholera cases electrical pumps to draw unsafe water from the old pipes
was 1.33/100000 population while in 2015 and 2016 the that may be contaminated with sewage disposal net due
rate was 8.2/100000 and 0.01/100000 respectively (11,12) to damge of both systems or contaminated with sewage
which explain that cholera can be seasonal or sporadic(2). stream in area not served by sewage net (5, 20).

In fact in 2016, 38 countries reported 132121 The people may digging wells due to either shortage
cases which represent 23% drop in the number of of tap water or unserved areas like outskirt and rural
cases reported compared with 2015 (172454 cases)(13),
areas, which also considered unsafe because not tested
although WHO considered the officially reported cases
bacteriolgicaly. Also, unplanned temporary camps for
represent only 5-10% of the actual number occurring
IDPs with shortage in provision of many standards
annually worldwide(14) because various factors influence
for basic life as electricity, clean water and sewage (5).
the underreporting such as weakness in the surveillance
system, use of inappropriate case definitions, laboratory Another explanation, that high population density in
diagnostic capacities, and reluctance to report for fear Urban areas and breakdown of water system and sewage
of negative economic impact on trading and tourisim, in disposal net have a great effect on spread of infection(16).
addition to limited registration in areas of conflicts (13).
Iraqi Ministery of Environment in 2009 explain
CFR in this outbreak was 0.6% while the CFR that the bacteriological contamination in water supply
in varies between governorates ranging between 2.5%-
2015 outbreak was 0.07% (11) and it is lower the CFR in 30% with average 16% which is beyond Iraqi National
Baghdad 2007 outbreak (2.2%) (5), in Camerone (6.1%) Driniking Water Standards and WHO Guidelines for
(15)
and (>5%) in Zimbabwe (16). In 2016, 38 countries Drinking Water permissible limit of 5% (20). Around
reported cholera outbreak with CFR 1.8% (2420 death), 250000 tones of sewage disposal thrown into Tigris river
of which 19 countries reported CFR > 1% while the which contaminat the water sources and water nework
overall CFR was 0.8% in 2015(13). The low CFR in (20). Also, many houses in suburb and rural areas illegaly
Iraq can be attributed to early detection and proper
puncture the raw water transfer pipes for domestic use.
mangement of cases that prevent death.
Nowadays, many water filtration factories (R.O) were
In the current study the mean age was around 30 manged by people and they are not under supervision of
years old (31.5 ± 19.95 years), this result agreed with the Health control of Iraq MOH. These factories sail water
results reported by Tamang et al (2005) a study to the families and not sure about its safety for drinking.
conducted in Nepal on 148 patients with acute Because of scarcity of water during dry seasons with
diarrhea showed that 46 patients (31%) were positive reduction in provision even in the areas served. Many
for V. cholerae O1 strains in which younger age group families with middle and low income, those living in
less than 30 years was mostly affected (17). Similarly, a poor and rural areas and IDPs in the camps depend on
study conducted by Jabeen et al (2003) in Pakistan also tab water but many people become gradually depend on
showed that the mean age of patients infected with V. R.O water (11).
cholerae serogroup O1 was 23 years when compared
with those infected with serogroup O139 their mean age
as 40 years (18).
The highest proportion of suspected cases was No conflict of interest to declare
among those who use both tab water and R.O (60.79%)
and followed by those who depened on tab water and Informed consent has been obtained from all patients
those who used R.O, (21.29%) and (16.9%) respectively,
as tab water may not be safe because there is no enough
free chlorine in water or high turbidity that prevent
chlorine function as the turbidity have a significant effect
on the efficiency of chlorine as a disinfectant (21). Also
R.O water may be unsafe because it is not under the
control of health authorities (11) and not tested physically,
chemically and biologically.

Conclusions
1. The rate of cholera cases was 1.33/100000
population and the CFR was 0.6%.
2. Although the highest significant proportion of
suspected cases were among age group 16-45years
but the risk of infection decreased after 1 year of
age.
3. Source of water is most important independent
variable that were more likely increased the risk
of cholera infection transmission, especially tab
water and R.O water as well as the river’s and
other source water (vehicle water).
4. Cholera cases reported from 11 governorates
out
of 18.
5. The outbreak occurred in autumn and reached the
peak on W47.

So we recommend the following

1. Strengthen the surveillance of suspected
cholera
cases specially active case detection.
2. Improve case management to decrease case
fatality rate below 0.2%.
3. Increase orientation about the disease,
especially
in the autumn season.
4. Control of the environment by callobration
with other menistries and health sectors that
responsible for purification of water, safe food
and good sanitation.
5. Health promotion by education of community
at
risk specially improving personal hygein.

No financial disclosure
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DOI Number: 10.5958/0976-5506.2019.01655.3

White Blood Cell, Procalcitonin, C-Reactive Protein and

TNF-α as Prognostic Factors in Pediatric Sepsis

SittiAizah Lawang1,4, Idham Jayaganda2, Dasril Daud3,4

1
Pediatric Department of Faculty Medicine Hasanuddin University, 2Wahidin Sudirohusodo Hospital,
3
PostGraduate School Students Faculty of Medicine, 4Hasanuddin University

ABSTRACT
Sepsis is the leading causes of morbidity and mortality in critical patients in many intensive care units.
There were numerous parameter and biomarkers available to confirm the presence of sepsis. The aim of this
study was to determine which one the parameter or biomarkers (white blood cell, CRP,procalcitonin and
TNF-α) has a role as an outcome predictor in pediatric sepsis patient. This prospective cohort study was
conducted in Pediatric Intensive Care Unit WahidinSudirohusodo hospital fromJanuari 2016untilMay
2017. A total of
108 sepsis patients were included. Plasma specimens were collected at admission, then the patients were
being followed up for survived or non-survived. The diagnosis of sepsis is using the International Pediatric
Sepsis Consensus 2005 criteria. Serum CRP,Procalcitonin TNF-α were measured using Enzyme Linked
Immunosorbent Assay technique. Initial serumprocalcitonin level and TNF-α in non-survived children with
septic were very significantly higher than those in the survived groupswith p=0.000 with OR2,46 CI(0,905-
6,697) in procalcitonin and p=0.000 with OR 44,69 CI(5,749-347,36)in TNF-α. The initial serum level of
PCT and TNF-α can be used as a predictor outcome of sepsis patient in children

Keywords: WBC, CRP, Procalcitonin, TNF-α, Sepsis,

Predictor
Introduction 78%, and 85%, while WBC, CRP, and ESR levels did
not have high accuracy in the diagnosis of bacterial
Septic shock is the primary cause of death in
infection in immunocompromised and neutropenia
intensive care units (ICUs). With a mortality rate in
patients.4By measuring serum PCT, antibiotic therapy
excess of 50%, it results in more than 100 000 deaths a
can be commenced or terminated to help doctors with
year in the United States.1Sepsis-induced organ failure
the diagnosis of suspected sepsis. Compared with CRP
leading to death appears to be due to the activation of a
1,2 and ESR levels, PCT levels are a better marker in
mediator cascade initiated by microbial components.
diagnosing lobar pneumonia in children.4
Several biomarkers have been suggested for the
PCT has been considered a reliable biomarker
early diagnosis of sepsis, including IL-1b, IL-8, TNF-α,
for differentiating sepsis from noninfectious systemic
and procalcitonin (PCT).3 Located in the lower range in
inflammatory response syndrome (SIRS).5,6
normal subjects, PCT, a calcitonin prohormone,
increases significantly in patients with bacterial In the case of suspected sepsis, drug therapy is
infections caused by a broad spectrum of gram-positive performed immediately after the patient’sadmission to
and gram-negative bacteria.4 In three separate studies, hospital, as any delay in treatment can worsen the
the sensitivity of PCT in the diagnosis of sepsis was disease. However, delays can occur due to the lack of
found to be 97%, specific symptoms of sepsis or inaccurate microbial
culture results. Blood cultures may be negative for
various reasons, such as the use of antibiotics before
Corresponding Author: hospital admission, which is common in our society,
SittiAizah Lawang although the results of blood cultures are reported
Pediatric Department of Faculty Medicine after at least
Hasanuddin University 48 hours. They may also be negative in the early stages
Email: [email protected] of SIRS and sepsis. Moreover, many organisms require
693 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 693

specific media and exclusive culture environments that After blood extraction, experiment should
are not available in most medical centers. However, be conducted immediately as well. Samples may
microbial cultures do not reflect the host’sinflammatory be stored at 2-8°C.Allowtheserumtoclotor 10-20
responses nor do they detect organ dysfunction.5 minutesatroomtemperature and centrifuge (at 2000-3000
RPM) for 20 minutes. Collect the supernatant carefully.
TNF αcan cause intravascular thrombosis, inhibit
muscle contractility of heart, lowers blood pressure When sediments occurred during storage, centrifugation
(shock), vascular dilation, and plasma leakage which should be performed again. Sample the assay, bring
then lead to septic shock.Therefore, it is important to samples to room temperature. First, add prepared
investigate the effects of cytokines as the prognostic sample 40 μl standards and ELISA solutions. times. Add
value in patients with sepsis. 1 chromogen solution A and B. Incubate for 10 minutes
at 37°Cforcolordevelopment. Thenaddstopsolution.
Previous studies showed numerous biomarker also Readthevaluewithin 10 minutes.
can determine the diagnosis in sepsis patients.1If we
can predict the outcome of patients with sepsis earlier, The data obtained are grouped into two groups of
thepatient can betreated more progressively, sothe patients; survived and non-survived. Then, suitable
mortality rate in patients with sepsis can be reduced. statistic method was chosen to analyze the data, which
Based on the fact above, it needs an approach from was univariate and bivariate analysis, power=80%,
biological parameter and biomarkers(WBC, CRP, PCT α=0,05.Chi factor was used to determine the significance
and TNF-α) to identify the role and prognostic value for of predictor factor relationship with the outcome of
sepsis. survived and non-survived. Mann withney test is
used compare the median initial serum of white blood
Material and Method cell, CRP,PCT and TNF-αlevel of the sepsis patient
to the outcome survived or not survived if data not
This study included children aged 1 month
normally distributed. For normality test, Kolmogorov-
to 18 years who were diagnosed with sepsis from
Smirnov test was used. Statistical Analysis was
December 2015 untilMay 2017 based on International
processedbyusingSPSS 21
Pediatric Sepsis Consensus of 2005, which was
treated in the Pediatric Intensive Care Unit (PICU)
WahidinSudirohusodo Hospital Makassar, Indonesia Results
[21]. Samples are the entire population that meets the
An observational study with prospective cohort
inclusion criteria. Inclusion criteria were patients with
approach in108 sepsis patient sin childrenhas been
sepsis, age 1 month to 18 years, who was willing to sign
conducte din Dr.Wahidin Sudirohusodo Hospital
an informed consent agreement. Exclusion criteria were
patients with trauma, burns, malnutrition, malignancy, Makassarf rom Januari 2016 until May 2017.
being received corticosteroid treatment and patients with The sample consisted of 40 sepsis and 68 with
immune deficiency
septic shock and then we observed for survived and non-
Written informed consent was obtained from all the survived. Fifty five sample in survived group
patients and their guardians, and all the patients were consisted37 (52,1%) boys and 34 (47,9%) girls, while in
examined clinically. Patients’ characteristics, including 53 sample non-survived group consisted of 18 (47,4%)
their ages; sexes; temperatures; respiratory rates; heart boys and 20 (52,6%) girls. Statistical analysis showed no
rates per minute; systolic and diastolic blood pressures; significant difference between the two groups with
alertness statuses at the time of admission and during p=0,59. The age was divided into ordinal. Statistical
hospitalization; underlying diseases. analysis showed that there wasno significant difference
in age between the two groups with p=0.11 (Table 1).
Sepsis is SIRS caused by either a suspected or
White blood cell (WBC), CRP, PCT and TNF-α was
proven infection. This study used the the International
classified into ordinal. There were no significant
Pediatric Sepsis Consensus 2005 criteria to diagnosis
difference in WBC,PCT and CRP between two groups,
sepsis.
only TNF-α showed very significant difference with
Five ml blood samples were used to measure PCT between survived and non- survived group with p=
levels, CRP levels, TNF-α, blood cultures and CBC-Diff 0,000
blood samples were taken.
Table 1: Sample Characteristic Conted…
Sepsis n = 108 TNF –α (pg/ml)
Non survive P < 200 0 (0,0%)
Characteristic Survive (55)
(53) value 201 - 500 44 (80,0%)
n (%) n (%) 501 – 1000 10 (31,3%)
Sex 1001-1500 1 (5,6%)
Boy 37 (52,9%) 33 (47,1%) 1501-2000 0 (0,0%)
0,59*
Girl 18 (47,4%) 20 (52,6%)
Age (years) Mann withney test is used compare the mean initial
serum of white blood cell, CRP,PCT and TNF-α level
1 month-1 year 15 (48,4%) 16 (51,6%)
of the sepsis patient to the outcome survived or not
1,1-5 year 14 (38,9%) 22 (61,1%)
survived because they were not in normal distribution.
5,1-10 year 7 (58,3%) 5 (41,7%) 0.11*
(Table.2). Serum level of WBC in survived group the
10,1-15 year 15 (68,2%) 7 (31,8%) mean was 20077,53 mg/dL and range 3640 to 61730
>15,1 4 (57,1%) 3 (42,9%) mg/dL. While in non-survived group was 22050,57 mg/
WBC (mg/dL) dL and range 3100 to 55200 mg/dL. Mann Whitney test
0-4.999 2 (33,3%) 4 (66,7%) results showed that there was no significant differences
5.000 – 9.999 6 (75,0%) 2 (25,0%) between the two groups with p=0.071
10.000-19.999 26 (59.1%) 18 (40,9%)
0,761* Serum level of CRP in survived group the mean was
20.000-29.999 13 (38,2%) 21 (61,8%) 45,27 mg/dL and range 0 to 238 mg/dLWhile in non-
30.000-39.999 4 (57,1%) 3 (42,9%) survived group was 68,70 mg/dL and range 0 to 289 mg/
> 40.000 4 (44,4%) 5 (55.6%) dL. Mann Whitney test results showed that there was
CRP (mg/dL) no significant differences between the two groups with
0 – 0.9 7 (70,0%) 3 (30,0%) p=0.104
1 – 2.9 7 (46,7%) 8 (53,3%)
Serum level of PCT in survived group the mean was
3 – 4,9 2 (66,7%) 1 (33,3%)
16,00ng/ml and range 0 to 210 ng/ml. While in non-
5 – 9,9 5 (100%) 0 (0%) survived group was 44,26ng/ml and range 19 to 210 mg/
10 – 19,9 5 (55,6%) 4 (44,4%) dL. Mann Whitney test results showed that there was
20 – 49,9 14 (51,9%) 13 (48,1%) very significant differences between the two groups with
>50 15 (38,5%) 24 (61,5%) 0,302* p=0.000 with OR2,46 CI(0,905-6,697)
PCT (ng/ml)
Serum level of TNF-α in survived group the mean
0 - 0,5 15 (88,2%) 2 (11,8%)
was 429,77pg/ml and range 269,36 to 1009,17 pg/ml.
0,51 – 2 10 (83,3%) 2 (16,7%) While in non-survived group was 848,92 pg/mland
2,1 - 10 19 (48,7%) 20 (51,3%) range 231,11-1784,68pg/ml. Mann Whitney test results
0,228*
10,1 – 50 5 (21,7%) 18 (78,3%) showed that there was very significant differences
50,1 – 100 4 (50,0%) 4 (50,0%) between the two groups with p=0.000 with OR 44,69
> 100,1 2 (22,2%) 7 (77,8%) CI(5,749-347,36)

Table 2: WBC, CRP,Procalcitonin and TNF-α between survived and non-survived

Survived Non-Survived P Value OR
WBC (mg/dL)
Mean 20077,53 22050,57
Median 16600,00 21250,00
*0,071
Std. Deviation 12,835,57 11,243,54
Minimum-Maximum 3640 – 61730 3100 – 55200
Conted…

CRP (mg/dL)
Mean 45,27 68,70
Median 22,00 40,00
*0,104
Std. Deviation 57,66 79,42
Minimum-Maximum 0 – 238 0 - 289
PCT (ng/ml)
Mean 16,00 44,26
Median 2,33 16,70
*0.000 2,46 CI(0,905-6,697)
Std. Deviation 37,09 65,99
Minimum-Maximum 0-210 19 - 210
TNF-α (pg/ml)
Mean 429,77 848,92
Median 414,56 825,07
*0,000 44,69 CI(5,749-347,36)
Std. Deviation 110,89 358,06
Minimum- Maximum 269,36-1009,17 231,11-1784,68
Discussion levels, peaking at approximately 24 - 36 hours. Some
studies of critically ill pediatric patients showed that the
The result so four research demonstrated
accuracy of PCT measurement in detecting bacterial
thatPCTlevel and TNF-αin non-survived children
infections is better than that of other markers, especially
withseptic were significantly higher than those in the
CRP. However, its sensitivity and specificity vary.13,14
survived groups.
In a cohort in an American tertiary hospital (78
This result similar withAygun F, that evaluated
children with criteria for sepsis and septic shock and 12
procalcitonin value is an early prognostic factor related
critically ill children without sepsis), persistently high
to mortality in admission to pediatric intensive care
PCT in children with bacterial sepsis was related to a
unit, the result showed there was statistically significant
poor outcome.14,15,16
relationship between PCT and TNF-α levels with MV
support, NIV, inotropic drug use, mortality, AKI, In this study, white blood cell and CRP showed not
hospitalization in the intensivecareunit,CRRT,andblood significantly difference between 2 groups. CRP generally
component transfusion.7,8 consider a nonspecific biomarker in sepsis.
Performing procalcitonin and TNF-α test routinely C-reactive protein (CRP), one of the biomarkers
in patients of sepsis can give rapid results in a day rather that has been in longer use in pediatric sepsis, is a non-
than the three to seven days required for bacterial culture specific, acute-phase protein that increases 4-6 hours
and can act as surrogate markers of microbial infection. after exposure to an inflammatory trigger Its levels
An increased of procalcitonin and TNF-α should be decrease rapidly with the resolution of inflammation
classified in higher risk of mortality and should be and is usually high in invasive bacterial infections.7,10
monitor and aggressive treatment started.9,10,11 In a systematic review of CRP diagnostic accuracy
for bacterial infection in non-hospitalized children
At high levels, TNF-α induce pathologic
with fever, the sensitivity and specificity of CRP were
abnormality of septic shock.12 Results of previous
estimated at 77% and 79%, respectively. However, its
studies have shown that TNF-α is a good marker for the
predictive value increases with the number of serial
diagnosis of sepsis, to assess the effectiveness of
measurements, thus rendering it possibly useful for
therapy, and prognosis of sepsis disease.1
therapeutic management. Serial measurements in which
Elevation of PCT levels usually occurs CRP levels remain elevated or increase after 48 hours
earlier of antibiotic therapy suggest treatment failure.8It is
during the course of infection than elevation of CRP
worth remembering that CRP is not a specific biomarker organ failure. Crit Care Clin 2003; 19: 413-440
for differentiating infection from inflammation or for
identifying specific infectious agents. As in the case of
other biomarkers, its use should always be associated
with bedside clinical evaluation of patients, and other
clinical decision-making criteria should always be used.
When available, the use of CRP combined with other
biomarkers including procalcitonin (PCT), IL-6 and IL-8
to increase its specificity in the diagnosis of
infectionsand to assess changes in therapeutic
approaches, including changes in antibiotic therapy, is
also promising.17,18

Limitations of this study, we only examined the

initial parameter and biomarker, not serially and we
didn’t analyzed the the outcome based on severity of
illness. While the strength of this study is a prospective
cohort design is used so that we can follow the effects of
these prognostic factors

Conclusion

The initial serum levels of procalcitonin and TNF-α

as the prognostic values for outcome in pediatric sepsis
hopefully can be an additional reference, for more
comprehensive sepsis treatment to prevent complications
and deaths. Sepsis patients with initial serum levels of
procalcitonin and TNF-α high, require a close
monitoring. Further research needs to be done with the
involvement of other factors are also associated with
sepsis outcomes such as genetic polymorphism, and serial
examination of the biomarker in patients with sepsis.

Ethical Clearance: taken from hasanuddin University

Ethics Committee, approval 423/H.4.8.4.5.31/PP-36-
KOMETIK/2016

Source of Funding: Self-funding

Conflict of Interest: The author declares no conflict

interest regard

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2. Carcillo JA. Pediatric septic shock and
multiple
3. Asadi F, Pourmoshtagh H, Mazloomzadeh S.
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wards of Ayatollah Mousavi Hospital, Zanjan.
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DOI Number: 10.5958/0976-5506.2019.01656.5

Reactive Thrombocytosis after Caesarean Section and

Normal Vaginal Delivery: Implications for Maternal
Thromboembolism and its Prevention

Suha Abduljaleel Wadi1, Ahmed Rifat Shakr1, Farah Muayyed Gebriel Shammas Youisif1
1
Senior Specialist in Obstetrics and Gynaecology, Al-Elwiya Maternity Teaching Hospital, Baghdad,
Iraq

ABSTRACT
Objective: To assess the duration and severity of reactive thrombocytosis after caesarean section and
after
normal vaginal delivery.
Design: A prospective study.
Setting: Al-Elwiya Maternity Teaching Hospital -Baghdad -Iraq.
Materials and Method: Seventy p r e g n a n t women who were admitted for delivery at Al-
Elwiaya Maternity Teaching Hospital were recruited into the study, the platelets count was measured at
the time of first visit in the antenatal period. The second sample was taken just before normal vaginal
delivery or caesarean section, followed by postnatal blood samples on days: 3, 8, 12, 16, 20 and 24 for the
measurement of platelets count. Seventy pregnant women were recruited and forty completed the study,
twenty of whom were delivered by normal vaginal delivery and twenty by caesarean section. A random
effects model was used to compare the platelets counts within and between the two groups (normal
vaginal deliveries group and caesarean sections group) to assess the severity and timing of reactive
thrombocytosis.
Results: Antenatally: there were no statistically significant differences in platelets count measurement
in the first antenatal visit and the pre delivery visit between the two groups. There was a slight fall in
the pre-delivery platelets count in both groups compared with first visit platelets count but this fall was
not significant. Postnatally: I. in the normal vaginal deliveries group; the platelets count continued to fall
until the third postnatal day, then it rose, reaching peak values, compared with first visit and pre-delivery
values at days 8 and 12 of the postnatal period which was statistically significant. The mean platelets count
decreased gradually thereafter. II. in the caesarean sections group; the platelets count gradually increased,
the rise started from the third post-operative day reaching a significantly high value, compared with first
visit and pre-delivery values at day 8 of the postnatal period. The platelets count peaked at days 12
and
16 of the postnatal period. The platelets counts remained significantly higher than the first visit and pre-
delivery values for 24 days after the caesarean section.

Keywords: Postpartum. Thromboembolism.Prevention. Postpartum Reactive

Thrombocytosis.

Introduction
Email: [email protected]

Corresponding Author:
Dr. Suha Abduljaleel Wadi
Senior Specialist in Obstetrics and Gynaecology,
Al-Elwiya Maternity Teaching Hospital,
Baghdad, Iraq
Phone: 009647700678773
In v i v o action of the clotting
mechanism is balanced by limiting reactions
that normally prevent clots from developing
in uninjured blood vessels and maintain the
blood in a fluid state. During pregnancy and
early puerperium, this balance between
coagulation and fibrinolysis is disturbed;
towards hypercoagualability. The maintenance
of normal haemostatic function requires the
successful interaction of three main
Components: Intact blood vessel wall, intact
platelets
699 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 699

function system, intact plasma coagulation and Methods of samples taking from the patients: Seventy
fibrinolytic components [1]. Platelets are central p r e g n a n t women who were admitted for delivery
to normal haemostasis and to all thromboembolic at Al-Elwiaya Maternity Teaching Hospital were
disease [2]; they appear to be necessary for the first recruited into the study, forty pregnant women
phase of haemostasis i.e. the formation of the initial completed the study, twenty of whom were
plug (temporary haemostatic plug)[1, 2]. Platelets are the delivered by normal vaginal delivery (NVD group)
smallest cellular elements present in human blood. and twenty by caesarean section(CS group). the
They are granulated non-nucleated, 2-4 μm in diameter platelets count was measured at the time of first visit
[1]
with a concentration from 150,000-400,000/µL[2, 3]. in the antenatal period. The second sample was taken
just before normal vaginal delivery or caesarean
section, followed by postnatal blood samples on days:
Patients and Method 3, 8, 12, 16, 20 and 24 for the measurement of platelets
count.
This study was done in Al- Elwiya Maternity
Teaching Hospital, Baghdad-Iraq. In cooperation with Statistics: A random effects model was used to analyze
the Department of Haematology in the same hospital, the platelets counts and to allow for the correlation
during the period from the 1st of June 2017 to the 1st of between the repeated measures of platelets counts. The
August 2018. statistical significance of the difference between mean
values was assessed by the student’s (t) test probability
Patients: value (p-value). Values of <0.05 were considered
significant.
*Selection of patients: Seventy pregnant women were
recruited into the study during the antenatal visits to the Results
antenatal care unit in the mentioned hospital. They had
Table 1: The mean & range of platelets counts of
an age-range of 19-39 years (mean 31 years).
Primiparous as well as multiparous women were first visit and predelivery counts in the two groups
included. The patients chosen were those who were Normal p-value
Caesarean
committed to deliver in the mentioned hospital and vaginal (Caesarean
sections
agreed to take part in the study after explaining its aims deliveries sections
Time of group
to them. They had to comply with the following group counts
blood (mean &
criteria: Gestational age was confirmed by history, (mean & compared
sample range of
clinical examination and ultrasonography done at 8-14 range of with
taking platelets
platelets vaginal
weeks of gestation. They had regular antenatal care, no counts)
counts) deliveries
major pregnancy complications, no history of essential (xl0 9/L)
(x109/L) counts)
hypertension or diabetes mellitus, no history of any
259.2 280.5
medical disorder affecting the platelets count. The 1st Visit 0.30
(157-393) (145-385)
following pregnant women were excluded from the
Pre- 254.15 261.2
study: women with medical disorders affecting the 0.72
delivery (138-384) (136-370)
platelets count such as thrombocytopenia, women with
history of malignant disease and genetic blood p-value
(pre-
disorders like antithrombin III deficiency. The following
delivery
puerperal women were later excluded from the study: counts 0.81 0.32
women who were delivered by instrumental delivery compared
like forceps or ventouse, those who suffered from with 1st
postpartum haemorrhage and those with anaemia. visit count)

*Questionnaire: A questionnaire was made for each There were no statistically significant
woman and it was in two parts: antenatal part and differences in the first visit and pre-delivery platelets
postnatal part. Serial blood samples were taken for the counts between the two groups. There was a slight
measurement of platelets count in the antenatal and in fall in the pre-delivery platelets count in both groups
the postnatal periods. compared with 1st visit platelets count but this fall was
not statistically significant (Table 1).
Table 2: The mean & range of platelets counts in the normal vaginal deliveries group
Normal vaginal deliveries group p-value compared with
Time of blood p-value compared with
(The mean & range of platelets pre-delivery platelets
sample taking 1st visit platelets count
count x 109/L) count
Antenatal blood samples:
1st Visit 259.2 (157-393)
Pre-delivery 254.15 (138-384)
Postnatal blood samples:
Day3 250.2 (132-424) 0.2 0.3
Day8 373.55 (264-650) 0.000001 ** 0.000001 * *
Day 12 378.3 (277-522) 0.000002 ** 0.000003 **
Day 16 327.4 (235-420) 0.0003* 0.0002*
Day 20 321.6 (234-392) 0.0004* 0.0003*
Day24 291.5 (176-393) <0.05* 0.04*
* Significant difference
** Highly significant difference (peak values)
In the normal vaginal deliveries group: The platelets count continued to fall until the third postnatal day, this
fall was not statistically significant. The platelets count increased rapidly after the third postnatal day, reaching peak
values at eighth and twelfth days of the postnatal period. These peak values were statistically significant compared
with first visit and pre-delivery values. The platelets count exceeded the upper limit of normal range (400x109/L) in
seven women (35%). The mean platelets count decreased gradually after the twelfth postnatal day (Table 2).

Table 3: The mean & range of platelets counts in the caesarean sections group
Time of blood Normal vaginal deliveries group p-value compared
p-value compared with 1st
sample (The mean & range of platelets with pre-delivery
visit platelets count
taking count x109/L) platelets count
Antenatal blood samples:
1st Visit 280.5 (145-385)
Pre-delivery 261.2 (136-370)
Postnatal blood samples:
Day 3 288.95 (148-421) 0.6 0.1
Day8 462.55 (269-635) 0.003* 0.002*
Day 12 537.15 (282-910) 0.0000002** 0.0000007* *
Day 16 542.3 (286-11 07) 0.000003** 0.000001 **
Day20 475.95 (264-690) 0.005* 0.001 *
Day 24 430.3 (194-798) 0.002* 0.005*
* Significant difference
**Highly significant difference (peak values)
In the caesarean sections group: Reactive thrombocytosis began on the third post-operative day, but the rise was
not significant. A significant high value of the platelets count was reached on the eighth post-operative day,
compared with first visit and pre-delivery counts. Peak values of platelets counts were reached at twelfth and
sixteenth postoperative days. These peak values were statistically significant higher levels, compared with the first
visit count and pre-delivery count. The platelets counts remained statistically higher than the first and pre delivery
values for 24 days of the postnatal period. So the rise in platelets count was continued for a longer period than in the
normal vaginal deliveries group.
The platelets count exceeded the normal range (400xl09/L) in sixteen women (80%) (Table 3, Figure 1).

Table 4: The mean & range of platelets counts in the caesarean section group compared with normal vaginal
delivery group
Normal vaginal deliveries Caesarean sections group p-value (Caesarean section
Time of blood group (The mean & range (The mean & range of s counts compared with
sample taking of platelets count x 109/L) platelets count x 109/L) vaginal delivery counts)
Antenatal blood samples:
1st Visit 259.2 (157-393) 280.5 (145-385) 0.31
Pre-delivery 254.15 (138-384) 261.2 (136-370) 0.73
Postnatal blood samples:
Day3 250.2 (132-424) 288.95 (148-421) 0.09
Day8 373.55 (264-650) 462.55 (269-635) 0.01
Day 12 378.3 (277-522) 537.15 (282-91 0) 0.001 *
Day 16 327.4 (235-420) 542.3 (286-11 07) 0.0001*
Day20 321.6 (234-392) 475.95 (264-690) 0.00005*
Day24 291.5 (176-393) 430.3 (194-798) 0.005 *
* Significant difference

There was a greater rise in the platelets counts in the caesarean section group compared with the
normal
vaginal delivery group.

The platelets counts in women delivered with caesarean section were significantly higher than in
women
delivered normally from day 12 to day24 of the postnatal period (Table 4).

Table 5: The mean & range of platelets counts in the normal vaginal delivery group & caesarean section
group (Summary of the results)
Caesarean p-value p-value
Normal vaginal p-value (Vaginal
sections group (Caesarean (Caesarean
Time of delivery group deliveries counts
(The mean & (The mean sections counts sections counts
blood sample compared
range of platelets & range of compared with compared
taking with antenatal
counts (x109/L)) platelets counts vaginal deliveries with antenatal
counts)
(x109/L)) counts) counts)
Antenatal blood samples:
1st visit 259.2 (157-393) 280.5 (145-385)
Pre-delivery 254.15 (138-384) 261.2 (136-370)
Postnatal blood samples:
Day3 250.2 (132-424) 288.95 (148-421)
Day5 373.55 (264-650) 0.000001 * 462.55 (269-635) 0.002*
Day 12 378.3 (277-522) 0.000002* 537.15 (282-91 0) 0.001** 0.0000007*
Day 16 327.4 (235-420) 542.3 (286-11 07) 0.0001 ** 0.000001 *
Day20 321.6 (234-392) 475.95 (264-690) 0.00005** 0.001 *
Day24 291.5 (176-393) 430.3 (194-798) 0.005** 0.005*

* Statistically significant high value compared with 1st visit & pre-delivery platelets counts.

** Statistically significant high value compared with normal vaginal delivery group.
NVD group C-S group
Fig. 1: Mean of platelets counts in the Normal Vaginal Deliveries group (NVD) and Caesarean Sections
group (C-S)
Significant thrombocytosis occurred at days 8 and 12 showed that some women recruited antenatally in the
after normal vaginal deliveries and caesarean sections. In vaginal delivery group required C-S. The coagulation
the normal vaginal deliveries group, the mean platelets parameters of women have been separately analysed in
count decreased gradually thereafter. In the caesarean both groups (vaginal and cesarean), the result was that
sections group, however, thrombocytosis continued till platelets counts and fibrinogen levels were significantly
the sixteenth day. It stayed at significantly higher level high till day 25 and 15 postpartum, respectively,
than in the normal vaginal deliveries group for 24 days after delivery (in C-S and VD groups). Reactive
after delivery. The platelets counts in women in the thrombocytosis that has been found to be a common
caesarean sections group were significantly higher than in occurrence during postpartum period is associated
women in the normal vaginal deliveries group from day with an increased incidence of thrombosis. Increased
12 to day 24 of the postnatal period (Table 5, Figure 1). fibrinogen is considered to contribute to hypercoagulable
state as well. Also their study shows an exaggerated
Discussion change towards hypercoagulability in cesarean sections
group compared with vaginal deliveries group [5].
Previous studies about this subject: Reactive
(secondary) thrombocytosis (elevated platelets count The overall incidence of VTE is approximately 1
> 450,000/μl and usually < 1,000,000/μl) . P Saha, D in 1000 Maternities (Pregnancy and Puerperium) The
[4]

Stott, R Atalla (2009) studied thrombotic changes during puerperal period is the highest risk period for VTE,
the postnatal period up to 6 weeks after delivery and when it increases 20-fold [6]. The risk is greater in
assess the extent of risk period. In their study the mean women who undergo c-section and is about 3 in 1000[7].
platelets counts were low on predelivery days and rose The risk was between 3-4 times higher for women
sharply to a peak on day 11, and continued to be who underwent an emergency (unplanned c-section) [8].
elevated until 25 days after delivery. The time to peak What is more important that the frequency of the
values is between (7-15) days, usually at a time when thrombosis and the risk of fatal PE development are 10
the patients are discharged from hospital. Their times higher after cesarean delivery compared with
prospective study, normal vaginal deliveries in the
postpartum period (as observed by autopsies) [9, 10]. On postpartum venous thrombosis and hence maternal
the basis of the results of our study and other studies, morbidity and mortality. It is the task of the
it has been shown that the time of development of gynaecologic surgeon to identify patients at risk for
thromboembolic complications coincides with the time development of a perioperative VTE and to apply the
of significant reactive thrombocytosis, which was more safest, most effective, and most cost-efficient method of
prominent in the caesarean sections group. So there prophylaxis to decrease the risk of thrombus
must be an association between reactive thrombocytosis development.
and the increased incidence of thromboembolic
complications, especially after operative delivery. Acknowledgment
Clinical presentation of postpartum VTE perceived
to be rare and does not reflect the true incidence DR. S.A. WADI Author thanks Mr. HAYDER
of silent venous thrombosis and many episodes of SAAD MAHDI for his exerted efforts in this study.
thrombotic events occur after discharge from hospital.
Ethical Clearance: The Research Ethical Committee
Thrombosis and thromboembolism continue to be the
at scientific research by the Arab Board for Medical
leading cause of direct death in UK and the rate has
Specializations/Ministry of Higher Education and
not changed significantly, with a mortality rate of 1.01
Scientific Research.
per 100,000 maternities [11], despite wide spread use
of thromboprophylaxis. There is a strong suggestion Conflict of Interest: The authors declare that they have
that inadequate thromboprophylaxis is a major cause no conflict of interest.
of this preventable condition.
Source of Funding: Self-funding.
Conclusion
REFERENCES
Our study data indicate that puerperium is a high-
risk period for the development of TED. A significant 1. Barrett K, Brooks H, Boitano S, Barman S.
thrombocytosis occurred at day 8 and day 12 after Cardiovascular Physiology: Blood as a
NDV and C-S. In NVDs group, the mean platelet count Circulatory Fluid and the Dynamics of Blood
reaches peak values at 8th and 12th days of the and Lymph Flow. Ganong’s Review OF Medical
puerperium and decreased gradually after the 12th Physiology.
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3. 2009; 34 (VI):Cardiovascular
Boundless. 587-588. System: Blood;
associated with a hypercoagulable state and increase
Hemostasis. Platelets. Boundless Anatomy and
risk of TED and it is more prominent in the C-S group
Physiology. Book Version 29, 2013; 16(4, 5).
compared to the VD group where it extended up to
24 postpartum. C-S was highlighted as the main risk
days 4. Liesveld J, James P, Reagan P.
factor for thromboembolism in the postpartum period. Reactive
This could partly explains why the risk of puerperal Thrombocytosis (Secondary Thrombocythemia).
thromboembolic events is about four times greater Blood Disorders.
& Dohme Corp.,MSD MANUAL.
a subsidiary of Merck
Merck Sharp
&
following C-S than following NVD Co., Kenilworth, NJ, USA; 2016.
Inc.,
more common ten days or more afterand these events are
delivery.
5. Saha P, Stott D, Atalla R. Haemostatic changes in
the Puerperium, 6 weeks postpartum (HIP Study)-
Recommendation implication for maternal thromboembolism. June
TE which is accepted as a complication, is a 13, 2009; P 1,4,5,6,7,10.
preventable one. Our recommendation is to consider 6. Troy Brown, RN. Guidelines Updated on
anticoagulant prophylaxis for at least 21-25 days after Thromboembolic Disease in Pregnancy. WebMD,
delivery. Perhaps this would reduce the incidence of LLC; 2015.
7. Norton A. C-Section Raises Risk of Blood Clots 10. Ozsoy S, Akduman B, Karapirli M, Tugcu H.
After Childbirth: Review. HealthDay; 2016. Death induced by pulmonary thromboembolism
after caesarean section. Roman. J. Legal Med.,
8. Boyles S. C-Section: Independent Risk Factors
2012, xx(4): 261.
for Postpartum VTE. www.medpagetoday; 2016.
11. Payne J. Mortality rates and main causes of death.
9. Glenview IL. (2016). Cesarean section
Maternal Mortality. WHO, May 19, 2016.
carries increased risk for postpartum venous
thromboembolism (VTE). Pregnancy and
Childbirth News – Science Daily; 2016.
DOI Number: 10.5958/0976-5506.2019.01657.7

The Impact of Hormonal Replacement Therapy on Herpes

Simplex Infection and Gingival Health in Post-Menopausal
Women

Suzan Mohammed Abdul Raheem1, Esra Hassan Abd Ali2, Mahmoud M A Elian3
1
B.D. S, M.Sc, Department, 2M.SC, Ph. D., Dentistry College, Mustansiriyah University, Baghdad, Iraq;
3
BSc, H.D.D. MSc.

ABSTRACT
The fluctuating levels of sex hormones throughout menopause have an influence on oral health and
periodontal disease. Deficiency of sex hormone during menopause and aging process mostly associated
with local tissue and salivary flow changes make oral tissue more prone for infection. Few studies that
assessed the rate of oral herpes simplex infection, bacterial growth and rate of gingivitis among
postmenopausal women receiving Hormonal Replacement Therapy. So aims of study to assess the
association of using the HRT and the incidence and recurrence rate of oral HSV infection, bacterial growth
and gingivitis among post-menopausal women.
Subjects and Method: a cross sectional study carried out between 1st.oct.2017-1st.May 2018. Participants
selected from private and outpatients’ clinics of Dentistry College of Mustansiriyah University. Fifty -eight
women in post-menopausal phase were selected randomly and categorized to two groups according to using
the HRT. Frequency, severity of herpes simplex, relation of recurrence status to duration of using HRT,
gingival index and bacterial growth were analyzed.
Results: Proportion of participants had mild, moderate and sever herpes simplex infection were 36.2,
34.5,
29.3% respectively. Proportion of subjects who are receiving HRT that reported sever herpes simplex
infection and recurrence rate of >8 per year was significantly lower in comparison to non-user (18.4
vs.50%), (13.2 vs.45%) respectively. No significant association was found between severity or recurrence rate
of HSV infection and duration of HRT use. Significant lower gingival index (GI) and bacterial growth
(p=0.01 for all) with women who were on HRT (1.6 vs.2.8),(74.5 vs.127.3) respectively. The mixed bacterial
isolate was reported with 55.2% of participants but no significant association found between type of isolate and
status of using HRT and recurrence of HSV infection, in addition it has impact on gingival health of post-
menopausal women

Keywords: Herpes simplex infection, Hormonal Replacement Therapy, post-menapouse

Introduction understood but endogenous factors such as immune
deficiency, emotional stress and exogenous factors
The menopauses are considered an important phase
such as UV radiation were implicated (4).However,
as this physiological state result in adaptive changes at
psychosocial stress is the most significant factor in the
systemic and oral level (1). Gums and teeth are mostly
recurrence of lesions (5).
liable to any hormonal changes on post menopause
and cant preserve a healthy equilibrium of useful and Certain types of bacteria promote viral disease
harmful bacteria within the oral environment (2). Because symptoms, suggesting these bacteria may aid viral
oral mucosa comprises estrogen receptors, variations in infection. Certain enteric viruses clarify how a bacterial
hormone levels affect the oral cavity (3). constituent—attached or independent to the bacterium
itself promotes the virus infection cycle (6)
Herpes simplex virus (HSV) transferred through
mucosal membrane and skin then spread to nerve Previously several studies were carried to assess the
tissues. The factors supposed to activate HSV not influence of (HRT) in adjusting periodontal
completely circumstances
706 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 706

in postmenopausal women due to a potential connection oral streptococci and incubated at 370C for 24 hours.
between osteoporosis and periodontitis (7). The HRT Triplicate plates were cultured for each dilution before
associated with a decreases of alveolar bone loss, but and after chewing.
a number of researches failed to revealed an inverse
relationship between alveolar bone density and Statistical Analysis
periodontal disease. Additionally, some authors failed to
establish positive effect for HRT on alveolar bone SPSS version 23 was used for data entry and
density(8). There are conflicting results on the role of analysis. The appropriate tests (student T test and chi-
square test) used to confirm significance. P <0.05 was
HRT on periodontal status in postmenopausal. While
considered significant
former research suggests that positive effects on
periodontal status, a recent report challenges these results
(9)
. Results

Hormonal Replacement Therapy has also been The participants were categorized to two groups;
linked with decreased level of gingival bleeding. It has 20(34.5%) was used HRT and 38(65.55) was didn’t. The
proposed that estrogen have an inhibitory influence mean age was 50.6 ± 4.6 (range 48–61 years) for HRT+
on gingival inflammation by inhibiting mediators that group and 49.8 ± 3.6 (range 47–62 years) for the control
includes IL-1, TNF-, IL-6, IL-1B, IL-8 and cellular group and this difference non-significant statistically
mechanism of inflammation (10). Conflicting findings (P=0.1).The clinical characteristics and type of isolate
about influence of HRT on probing pocket depth and were summarized in table.1.
attachment level (11).In several studies, the risk of tooth
loss lowered among women who used HRT than those Table 1: Descrptive characteristics of studied group
who did not (12)
No. %
The objectives of this study was to evaluate the rate, Mild 21 36.2%
severity and recurrence rate of herpes simplex infection status of HR Moderate 20 34.5%
in addition to gingivitis and bacterial growth status in a
Sever 17 29.3%
group of post-menopausal women receiving HRT.
<4 11 19.0%
Frequency of
Materials and Method 4-8 32 55.2%
recurrence of HS
>8 15 25.9%
Cross sectional study carried out from 1st Oct.2017to Single 26 44.8%
1 May 2018, 58 women at postmenopausal phase were
st Type of isolate
Mixed 32 55.2%
selected from outpatient clinic of Dentistry College of
Mustansiriyah University and private clinics involved. Our data indicated, there was significant association
The participants were categorized to two groups (p=0.005) between using the hormonal replacement and
according to status of receiving the HRT. The participant
status of herpes simples as the frequency of subjects
received any immunosuppressive therapy, any
with moderate and sever status of herpes simples was
medicine that affects the salivary flow, with any harmful
lower with group who are receiving HRT in compare to
habits such as smoking, chewing tobacco, alcohol etc.
was excluded. All participants were examined looking for control group as seen in table 2
herpes simplex infection and asked about history of
similar condition and it frequency per year. The Table 2: Association between severity status of
frequency, severity and status of recurrence of herpes Herpes simplex and status of using the HRT
simplex infection and bacterial growth and their
association with using of HRT were Using HRT
p-
Yes No
value
compared according to status of HRT use. No. % No. %
The growth of bacteria was assessed in two groups. Severity Mild 19 50.0% 2 10.0%
status of Moderate 12 31.6% 8 40.0% 0.005
-10-6), the three last dilutions (10-4- 10-6) were cultured herpes Sever 7 18.4% 10 50.0%
on BHI-A ( Brain Heart Infusion Broth and Agar ) for
total bacterial count and on MSF-A for counting of
The results of current study showed that the or single isolate and status of using the hormonal
proportion of subjects who were presented with high replacement therapy as displaced in table 4.
attack frequency (4-8 or >8/year) of herpes simplex
significantly lower with group who were used HRT as
Table 4: Association between type of isolate and
seen in table 3.
status of using the HRT

Table 3: Association between frequency status of Using HRT

p-
herpes simplex and status of using the HRT Yes No
value
No. % No. %
Using HRT Type of Single 18 47.4% 8 40.0%
p-
Yes No isolate
value 0.5
No. % No. % bacterial
Mixed 20 52.6% 12 60.0%
Frequency <4 26 68.4% 5 25.0% growth
of The data showed there was no significant
4-8 7 18.4% 6 30.0% 0.01 association between the duration of using the
recurrence/
year >8 5 13.2% 9 45.0% hormonal therapy and status of herpes simplex infection
The results revealed the was no significant or frequency of recurrence (p=0.3, 0.7) respectively as
association between type of growth in term of showed in table.5.
mixed

Table 5: Association between duration of using the HRT, severity status and frequency of Herpes simplex
infection
Duration/year
<2 2-4 >4 p-value
No. % No. % No. %
Severity Mild 0 0.0% 1 20.0% 1 20.0%
status of Moderate 3 30.0% 2 40.0% 3 60.0% 0.3
herpes Sever 7 70.0% 2 40.0% 1 20.0%
Frequency <4 2 20.0% 1 20.0% 2 40.0%
of 4-8 3 30.0% 1 20.0% 2 40.0% 0.7
recurrence >8 5 50.0% 3 60.0% 1 20.0%

The results of current study demonstrated that the mean value of CFU colony forming unit of bacteria was
significantly lower (p=0.01) with group of subjects who are using the HRT in compare to control group (127.3, 5.4)
respectively as displaced in table 6.

Table 6: The mean value of CFU and GI according to status of using the HRT
Using HRT N Mean Std. Deviation p-value
Yes 38 74.5 5.4
CFU 0.01
No 20 127.3 6.7
Yes 38 1.6 0.7
GI 0.01
No 20 2.8 0.3
The findings of current study showed there was no of oral discomfort and changes could occur (13).Few
significant correlation between the duration of hormonal studies focused on gingival changes and flow of
therapy used and CFU colony forming unit or GI saliva and other mucosal discomfort during and after
gingival index as by using pearson correlation analysis. menopause (14)

Discussion The results of this study show there was significant

association between using the hormonal replacement
Menopause is usually followed by a number of
therapy and decreasing frequency, recurrence, growth of
physical changes in oral cavity therefor high prevalence
and severity of herpes simplex infection as the
results
revealed that the attack of herpes simplex 4-8 or >8/ related diseases and, consequently, by the presence of
year significantly lower with group who were used multiple pathologies and comorbidities characterized by
HRT. This relationship can be explained by the chronic processes, such as inflammation (19).
capability of HSV to create latent infection in autonomic
Many studies reveal that salivary pH, buffering
ganglia that forcefully replicate or reactivate by
capacity and flow rate play important roles in oral
physical, hormonal, or emotional stress that mostly
mucosal defense. When salivary flow rate is reduced,
improved with the using of HRT. (13).
susceptibility to various oral diseases enhanced (20).
The mean of GI and CFU of bacterial growth Some studies shown lower salivary flow rates in
was lower with group who are receiving hormonal postmenopausal women, one was carried out by Parakh
replacement therapy in compare to control group and D et al , that reduction give route to poor oral hygiene
(21)

this finding documente d that hormonal replacement and more susceptibility to oral physiological changes.
therapy during menopause has positive impact on oral A questionnaire study by Jansson and his co-workers
health but the exact mechanism behind that yet not well (2003)
(22)
had been stated; there was more xerostomia
understood and further researches are recommended to among postmenopausal women who did not use HRT in
highlight this association. comparison to those used hormonal therapy. The same
authors proposed that some oral symptoms might be
Studies had explained that negative life occasions associated with estrogen deficiency, but oral symptoms
are more dependably in the beginning or exacerbation do not develop immediately after menopause but some
of diseases and the association between significant years later. It may also be that women with the severe
negative life events and disease was mediated by the symptoms decided to use HT and use of HT decreased
immune system. Studies has been shown that emotional their symptoms to the same level as in premenopausal
stress can modify the immune system through the neural women. The using of HRT could act in some way
and endocrine systems in at least three different ways;- through increasing the salivary flow rate and that in turn
through the autonomic nervous system path way, could take part in minimizing the risk of oral infection in
through the release of neuropeptides and Through the post-menopausal women.
release of hypothalamic and pituitary hormones(15,16), so
the suggestion of using HRT in some way could In current study, we found that the salivary
modulate the immune response to stressful conditions bacterial growth was lower with group of subjects that
that mostly associated with post menopause phase and on hormonal replacement therapy while a study was
reduce the incidence of viral infection and bacterial conducted by Leimola-Virtanen R et al (23) that
overgrowth calculated salivary bacteria was found the HT seemed to
have no effect on the amount of the total salivary
The behavioral mechanism supposed that people bacteria in post-menopausal women.
suffering from psychological illness may exacerbate
poor health behaviors, such as smoking or drinking
more frequently; consuming unhealthy diet and don not Conclusion
their oral hygiene. This behaviors leads to increased The rate, recurrence rate and severity of herpes
oral biofilm burden and decreased resistance of the simplex infection was lower among postmenopausal
periodontium to inflammatory breakdown. In an early women on hormonal replacement therapy.
study, adult subjects under financial strain and exhibiting
poor coping behaviors were reported to be at increased
risk for severe periodontitis (17). Periodontitis patients Acknowledgement
with inadequate stress behaviors strategies were
The authors would like to thank Mustansiriyah
proposed to be at higher risk for severe periodontal
University ( www.uomustansiriyah.edu.iq)Baghdad –
diseases (18)
Iraq for its support in the present study
According to previous finding concerning the effect
Conflict of Interest: Nil
of stress in exacerbating the periodontitis status so it
may effect in same manner and exacerbate the gingivitis Source of Funding: Self
status that could be reduced with using the HRT that
mostly reduced the stress Ethical Clearance: Our article has not considered
for
Numerous studies showed that aging of human publication in another journal
being is characterized by increased susceptibility to
age-
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5. Smith JS, Robinson NJ. Age-specific prevalence disease. J dent Sci Res. 2010; 1:54–61.
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8. Taguchi A, Sanada M, Suei Y, Ohtsuka M,
Nakamoto T, et al. Effect of estrogen use on tooth 20. Nair. D B. Effect of Saliva in oral health of
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9. Pizzo G, Guiglia R, Licata ME, Pizzo I, Davis 21. Parakh D et al. Evaluation of the effect
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DOI Number: 10.5958/0976-5506.2019.01658.9

The Relationship between Neck Pain and Hand Dexterity

among Violinists in Kota Kinabalu, Sabah, Malaysia

Tay Xin Le1, Rajkumar Krishnan Vasanthi2, Jim Brown Clement3

1
Physiotherapist, Biorehab Physiotherapy Centre, Kota Kinabalu, Sabah, Malaysia; 2Clinical
Coordinator cum Lecturer, 3Lecturer, INTI International University, Nilai, Malaysia

ABSTRACT
Background and Objective: Violinists are commonly affected by neck pain a condition commonly
associated with upper limb dysfunctions and there is limited information regarding the effects of neck pain
on hand dexterity in violinists. The objective is to investigate if neck pain significantly affects tapping
speed and the relationship between degrees of neck pain on tapping speed in violinists with neck pain.
Materials and Method: 34 violinists with neck pain (N = 23) and without neck pain (N = 11) were
recruited. Tapping speed of the index-middle, middle-ring, and ring-little fingers of both hands were
measured with HLTapper V.1.0 application. Analyses were done to identify significant differences in
tapping speed between two groups; and to correlate degree of neck pain and tapping speed.
Findings: Significant difference in tapping speed of right middle-ring (RMR) finger between violinists
with and without neck pain (p = 0.018). Strong negative linear correlation between degree of neck pain and
tapping speed of RMR finger in violinists with neck pain was found ( = -0.845, p = 0.001).
Conclusion: Tapping speed of the RMR finger may be affected by neck pain in
violinists.

Keywords: Neck Pain, Tapping Speed, Fine motor skills, hand dexterity in
violinists
Introduction function is often impaired in association with neck pain
disorders.(3)
Upper limb dysfunction can borne from a variety
of clinical conditions, neck pain has been cited as one Manual dexterity is defined as the ability to
of the most commonly associated issue.(1) Patients with coordinate the fingers and to manipulate objects in a
neck problems were likely to present with upper limb timely manner. (4) It is also the ability to integrate
disability; with the most classic example being upper precision and speed with finely coordinated movements
limb pain, motor weakness, sensory deficits, and loss of the arm, hand, and fingers.(5) For musicians, playing a
of function due to cervical radiculopathy.(2) In a musical instrument often involves highly coordinated
study hand movements and profound digital precision and
79.6% of patients with non-specific neck pain reported velocity.(6) The speed, fluency, & tempo required for
that upper limb activities aggravated the neck pain musical performances of elite instrumentalists crowned
thereby further cementing the statement that upper limb musical expertise as the ultimate example of elite
performance in complex hand dexterity, thus marking
excellent fine motor skills as an essential component for
Corresponding Author:
musicians to perform well on their instrument.(7)
Rajkumar Krishnan Vasanthi
Clinical Coordinator cum Lecturer, A musician’s technique pertains to the way he holds
Department of Physiotherapy, the instrument, the force applied when playing, and the
Faculty of Health & Life Sciences, frequency of awkward static or dynamic postures. Static
INTI International University, Putra Nilai, loading involves prolonged, sustained muscle
71800 Nilai, Negeri Sembilan, Malaysia contraction and stress across a joint, the surrounding soft
Phone: 0060129410541 tissue, and bony structures. On the other hand,
Email: [email protected] dynamic load is
711 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 711

the force applied to the muscles, joints, and supporting 1.1. Following that, the subjects answered the NPAD
structures by movements. (8) While the position of the left
shoulder is relatively fixed, the left hand regulates the
tone and pitch of the sounds produced by pressing the
strings along the length of the finger board, in such a
way that a higher pitched sound is generated when the
string is pressed closer to the sound bridge, thus the
position of the elbow, forearm, and wrist changes
according to the required tone.(9) Here, stabilizing
efforts from the neck and shoulder musculatures are
needed to allow precision work in the hands and fingers
when playing the violin. Thus, excessive overuse or
misuse may cause fatigue of the stabilizing muscles,
consequently resulting in neck pain and discomfort,
possibly due to muscle spasms and nerve
compression. (10) Another study found that violinists
with unilateral neck pain showed less lower trapezius
strength on the ipsilateral side compared to the
contralateral side; likely due to the alteration of muscle
usage between the upper trapezius and lower trapezius in
stabilizing the violin due to pain.(11) Alteration of posture
due to neck pain can be associated with difficulties in
other regions, such as dexterity in the hands.(12)

Although musicians commonly report pain-

associated decrease in fine motor skills, there is limited
information regarding the effects of neck pain on hand
dexterity in high string musicians.

Materials and Method

34 violin players (teachers, students, & performers)

were recruited from University Malaysia Sabah, Sabah
Institute of Art, & various music academies in Kota
Kinabalu, Sabah upon approval from the relevant head
of department or musical director of the aforementioned
musical institutes. Inclusion criteria are, aged
between
18 – 50 years old, playing the violin for at least two
years and two hours per week. Has playing related non-
specific neck pain (for symptomatic group) and does
not have neck pain for the last 12 weeks (for control
group). Whereas the participants are excluded if the,
history of trauma or surgery to the neck, shoulder,
arm, forearm, and hand, history of pregnancy (to avoid
possible confounding factors such as pregnancy-related
peripheral neuropathies e.g. carpal tunnel syndrome).

The subjects were recruited via convenience

sampling from the aforementioned musical institutes.
Group allocation was done according to the flow
chart
712 Indian Journal of Public Health Research
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 712
questionnaire. All participants provided written consent
to participate in this study. Data collection was conducted
over a period of six month from July 2018 to December
2018. Institutional ethical approval was obtained from the
Research and Ethical Committee of INTI International
University before proceeded with this study.

For the timed tapping test, the subjects were seated

with their left forearm rested on a table, with the wrist
neutral and relaxed. They were then asked to alternately
tap each side of the rectangle with their index finger and
middle finger as fast as possible for 10 seconds on the
HLTapper V.1.0 application. They were then given a
rest period of 30 seconds before repeating the test for
two more times. The procedure is then repeated for
the middle finger and ring finger; followed by the ring
finger and little finger. The same test is done for the
right hand as well. The number of taps performed per
second are then recorded for each hand. After the above
data have been recorded, group matching was performed
and reassigned as depicted in the flow chart 1.1.

Figure 1.1 Flow chart of data collection

Findings
SPSS V.22 was used, with the alpha set at 0.05.
Preliminary testing of sampling distribution showed
that for tapping speed of all finger combination
groups were normally distributed except for the
right
middle-ring (RMR) finger combination of the neck finger combination groups except for the RMR finger
pain group, as shown by their p-values in table 1.1. combination group where Mann-Whitney test instead.
Thus, the independent T-test was performed to analyse The Spearman’s rho correlation coefficient was done to
the difference in tapping speed between violinists analyse the relationship between degree of neck pain and
with neck pain and those without neck pain for all tapping speed.

Table 1.1: Tapping speed of all finger combination groups and their p-values
Groups
Neck pain group Non-neck pain group
Finger combination
Right index-middle (RIM) p = 0.084 p = 0.200
Right middle-ring (RMR) p = 0.026 p = 0.200
Right ring-little (RRL) p = 0.200 p = 0.200
Left index-middle (LIM) p = 0.200 p = 0.200
Left middle-ring (LMR) p = 0.200 p = 0.200
Left ring-little (LRL) p = 0.200 p = 0.200

No significant between-group differences were found for age, gender, BMI, years of playing, total playing hours
per week, and handedness (p > 0.05) in table 2.1.

Table 2.1: Sample characteristics and distribution of subjects

Violinists with neck pain Violinists without neck pain
Demographics p-value
(N = 11) (N = 11)
RIM: p = 0.561
RMR: p = 0.294
19 to 40 20 to 45 RRL: p = 0.460
Age (Year)
(Mean ± SD = 29.27 ± 7.54) (Mean ± SD = 27.55 ± 8.29) LIM: p = 0.667
LMR: p = 0.382
LRL: p = 0.540
RIM: p = 0.800
RMR: p = 0.889
Gender (Male/ RRL: p = 0.276
5/6 6/5
Female) LIM: p = 0.519
LMR: p = 0.359
LRL: p = 0.267
RIM: p = 0.963
RMR: p = 0.873
20.03 to 24.03 18.73 to 24.22 RRL: p = 0.093
Body mass index
(Mean ± SD = 22.74 ± 1.34) (Mean ± SD = 21.85 ± 1.92) LIM: p = 0.251
LMR: p = 0.342
LRL: p = 0.789
RIM: p = 0.794
RMR: p = 0.604
Years of playing 1 to 12 2 to 18 RRL: p =0.523
(Years) (Mean ± SD = 5.27 ± 3.36) (Mean ± SD = 8.09 ± 5.00) LIM: p = 0.190
LMR: p = 0.211
LRL: p = 0.755
RIM: p = 0.766
RMR: p = 0.493
Total playing hours 7 to 24.5 2 to 21 RRL: p = 0.717
per week (Hours) (Mean ± SD = 15.77 ± 6.25) (Mean ± SD = 10.63 ± 6.82) LIM: p = 0.639
LMR: p = 0.132
LRL: p = 0.366
Conted…
RIM: p = 0.150
RMR: p = 0.285
Handedness (Right/ RRL: p = 0.853
7/4 10/1
Left) LIM: p = 0.572
LMR: p = 0.414
LRL: p =0.076

Analyses with the independent T-test found no significant differences in tapping speed of the RIM finger; RRL
finger; LIM finger; LMR finger; and LRL finger combination groups of both hands (p > 0.05) between neck pain
and non-neck pain groups. On the other hand, tapping speed of the RMR finger combination in neck pain group
(Median
= 8.20) differed significantly with a large effect size from the non-neck pain group (Median = 9.43), U = 28.5, z =
-2.10, p =0.018, r = -0.633 using the Mann-Whitney test (p < 0.05).

Table 3.1: Mean tapping speed of both hands between neck pain and non-neck pain groups and their p-values
Groups
Neck pain group Non-neck pain group p-value
Finger combinations
RIM 10.70 taps/s 12.07 taps/s p = 0.068
RMR 7.88 taps/s 9.29 taps/s p = 0.018
RRL 6.32 taps/s 7.15 taps/s p = 0.211
LIM 11.15taps/s 11.57 taps/s p = 0.617
LMR 8.27 taps/s 8.95 taps/s p = 0.440
LRL 6.38 taps/s 7.10 taps/s p = 0.282

Spearman’s rho correlation coefficient found a significant relationship between tapping speed of the RMR finger
combination and the degree of neck pain, = -.845, p =. 001. This suggests a strong negative linear correlation
between the two variables - indicating that as the degree of neck pain increases, the tapping speed of the RMR
finger fingers decreases.

Figure 2.1: Relationship between the degree of neck pain (VAS) and tapping speed of the RMR fingers
(taps/s) in violinists with neck pain
Discussion The current study also found that there was a
significant, strong negative linear correlation between
The results of this study suggested that there were no
the degree of neck pain and tapping speed of the RMR
significant differences in tapping speed in all the finger
finger among violinists with neck pain. These findings
combinations between violinists with neck pain and those
are in agreement with that of Osborn and Jull, which
without neck pain except for the RMR finger
found a moderate to high correlation between the
combination, which demonstrated a significant difference
severity of neck disorder and level of upper limb
of large effect size between the two groups. These results
disability – in that patients with more severe neck pain
are in partial agreement with a study, which compared the
presented with more limitations in their upper limb
sensorimotor function of violinists with and without neck
function. However, the type of upper limb functions
pain to measure different motor aspects of the upper
examined by Osborn and Jull differs from the current
limb/hands. (7) The differences between the results of these
study, in the sense that Osborn and Jull studied
studies may be due to the fact that the current study
recreational movements which involved gross motor
employs a timed alternate finger tapping method to assess
function; whereas the current study examined fine
the dexterity of the subjects, which is a more similar
motor tasks.
movement to those employed when playing a violin in
comparison to the traditional way of assessing tapping The first potential limitation of the current study is
speed by single finger tapping of the index finger; and the selection of the measurement tool. As of now, there
thus may be more accurate than the latter in detecting is no consensus regarding the most suitable outcome
significant differences in the tapping speed between two measure tool for assessment of hand dexterity in
groups of subjects. Nonetheless, non-specific neck pain musicians. It future studies, perhaps an outcome
has been shown to have a significant impact on upper measure tool that allows the musician to assume the
limb function, as indicated that 80% of patients with non- exact basic position adopted during their musical
specific neck pain reported difficulties with upper limb performances may allow better analysis of the data, as
tasks due to the pain.(3) The difference between this study this may minimize any carry-over effect from their
and the current study is evident in the type of upper limb experience with playing other instruments.
function studied – where Osborn and Jull examined gross
movements such as lifting objects, gardening, and Conclusion
household chores; the present study examined fine and
precision-oriented motor tasks of the hand and fingers. The study concludes that there is significant
A similar interpretation can be drawn from results of a difference in tapping speed of the RMR finger
study by (13), which found that chronic mechanical neck combination between violinists with neck pain and
pain populations had less accurate proprioception in the violinists without neck pain. However, it also identified
shoulder and wrist. Altered input from neck muscles that no significant differences in tapping speed of the
secondary to pain and fatigue may affect sensory input to RIM finger; RRL finger; LIM finger; LMR finger; and
the central nervous system, consequently impairing upper LRL finger combinations between violinists with neck
limb proprioception and limit the performance of pain and violinists without neck pain. Furthermore, the
precision tasks. Furthermore, the results of the current current study also found that there is a significant and
study may also be explained by the fact that the structures strong negative linear relationship between degrees of
of the right upper extremity is often placed under high neck pain and tapping speed of the RMR finger in
levels of dynamic loading during playing. Here, the violinists with neck pain, in which tapping speed of the
right upper extremity is used to produce larger range of RMR fingers decreases as the degree of neck pain
motions compared to the left upper extremity during increases.
bowing movements, with the right shoulder placed in an
increasingly abducted and internally rotated position Acknowledgements
depending on which strings are played. When musicians
are required to play quickly and frequently under these The author would like to thank University Malaysia
conditions, accumulation of physical stress from dynamic Sabah, Allegrow Music School, Prelude Music School,
loading can cause fatigue and micro-damage to the Concept Music School Kota Kinabalu, Harmony Music
musculotendinous structures of the proximal stabilizing School, Musical studies department from Sabah Institute
muscles and upper limb, ultimately resulting in pain, of Art, Joan’s Music Centre for their generous support in
discomfort, and dysfunction.(9) enabling the completion of this research.
Source of Funding: Self-funding 6. Sims et.al. Hand Sensibility, Strength, and Laxity
of High-Level Musicians Compared to Non-
Conflict of Interest: Nil
Musicians. J Hand Surg Am. 2015 Oct; 40(10)
7. Steinmetz, A. & Jull, G. Sensory and Sensorimotor
REFERENCES
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for people with neck pain: a systematic review of
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measurement and practical properties. Syst
safety: Preventing playing-related musculoskeletal
Rev.
disorders. AAOHN J. 2006 Jul; 54(7):309-16.
2015; 4:43
9. Lee et. al. Musicians› Medicine: Musculoskeletal
2. McLean et.al. An investigation to determine the
Problems in String Players. Clin Orthop Surg.
association between neck pain and upper limb
2013 Sep; 5(3): 155–160
disability for patients with non-specific neck
pain: a secondary analysis. Man Ther. 2011; 10. Morales, G. & Antunes, A. Musculoskeletal
Oct;16(5):434-9 disorders in professional violinists and violists.
Acta Ortop Bras. 2012; 20(1):43-7
3. Osborn, W. & Jull, G. Patients with non-specific
neck disorders commonly report upper limb 11. Kim, S. H. & Park, K. N. The Strength of the
disability. Man Ther. 2013; Dec; 18(6):492-7. Lower Trapezius in Violinists with Unilateral
Neck Pain. Phys Ther Korea 2014; 21(4): 9-14.
4. Wang et.al. Assessing Dexterity Function: A
Comparison of Two Alternatives for the NIH 12. Watson, A. The Biology of Musical Performance
Toolbox. Retrieved from: J Hand Ther. 2011; and Performance-related Injury. Scarecrow Press;
Oct-Dec;24(4):313-20 2009.

5. Özcan, et.al. Comparison of Pressure Pain 13. Abuchandani, D. & Parkar, B. Comparison
of Upper Limb Proprioception in Chronic
Threshold, Grip Strength, Dexterity and Touch
Mechanical Neck Pain Patients with Age-Sex
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1428
DOI Number: 10.5958/0976-5506.2019.01659.0

Antibiotics Usage and Their Cost in the Pediatric Wards of

Salah Aldin Teaching Hospital

Thikra M. Al-Kumait1, Emad Maaroof Thakir2, Hind Mutar Ibrahim2, Alaa H. Alwan2
1
Department of Family & Community Medicine, College of Medicine, Tikrit University, 2Department of
Pediatrics, College of Medicine, Tikrit University, Salah Aldin, Iraq

ABSTRACT
Background: Antimicrobials are among the most commonly used and misused of all drugs. The inevitable
results of their common and widespread use has been the emergence of antibiotic-resistant pathogens,
fueling an ever-increasing need for new drugs at a time when the velocity of antimicrobial drug
development has slowed significantly, therefore aim of this study is reducing inappropriate antibiotic use
which thought to be the best way to control resistance and reserve money spent for buying.
Material and Method: This descriptive study was held in the wards of Salah Aldin Teaching Hospital
(STH), from (1-31) January 2017, the total number of collected sample is 1700 cases of inpatient were
treated with antibiotics from a total of 2150 inpatient and only 647 cases in the pediatric wards who treated
with antibiotics were included in the study. The study involved with determining the definite diagnosis,
cause of admission, rational cost for using antibiotics and the duration of the treatment.
Results: Total numbers of cases who treated with antibiotics were 647 cases in pediatric wards only and
the number of antibiotics which had been spent during that month as follow: 482 cephalosporins vials, 199
penicillins vials, 235 metronidazole bottols, 54 amino-glycosides, 35 glycopeptide, 31 Flouroquinolone,
and
17 macrolides vials respectively as registered in the pharmacy books and wards (more than one antibiotic
might be prescribed to one case). The total cost was 6194$ only in pediatric wards from a total 23929$ cost
of antibiotics used in the whole wards of Salahaldin Teaching Hospital (STH).
Conclusion: The antibacterial agents are used in the wards of the hospital roughly, without differential tests
and without any respect to the guidelines of judicious AB use to decrease the resistant. Cephalosporins are
the most commonly used AB in all the five wards of STH, As well as the total cost of using AB in STH for
only one month is about 23929 $, 6194$ in pediatrics. enormous amounts of AB used in STH can easily
lead to serious problems of resistant infections, also huge amounts of AB dispensed for chest infections and
GE (usually are viral in nature).

Keywords: Antibiotics usage; Cost; Pediatric wads; Salahaldin Teaching

Hospital.
Introduction diseases in the United States have begun to increase,
to some extent due to increases in antimicrobial
An antibacterial are compounds or substances that
resistance(1,2). So antimicrobial agents are among the
kill or decelerate the bacterial growth. The discovery
most commonly used and misused of all drugs. The
of antimicrobials is one of the most great and best
inevitable result of their common and wide spread use
medical achievements of the 20th century. Before the
has been the emergence of antibiotic-resistant
antimicrobial time, patients who contracted common
pathogens, fueling an ever-increasing need for new
infectious diseases developed significant morbidity
drugs at a time when the velocity of antimicrobial drug
or mortality. The discovery of penicillin in 1927, after
development has slowed significantly. Reducing
that; the subsequent discovery of other antimicrobials,
inappropriate antibiotic use is thought to be the best way
contributed to a considerable decline in mortality related
in resistance control (3).
to infectious disease during the next five decades.
However, since 1980, the mortality caused by infectious Antibiotics have three principal uses: empirical
therapy, definitive therapy, and prophylactic therapy.
717 Indian Journal of Public Health Research
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Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 717

When used as empirical therapy, the antibiotic(s) should antibiotic choice based on local patterns of
cover all the possible pathogens, because the infecting susceptibility, proper antiseptic technique to ensure
organism has not been identified. Either combination infection rather than contamination, right use of
therapy or, treatment with a single broad-spectrum agent prophylactic antibiotics in surgical procedures,
may be employed. Once the infecting microorganism infection control procedures to isolate the pathogen,
is identified, the course is completed with a narrow- and strict compliance to hand hygiene (2,9).Most viral
spectrum, low-toxicity drug. Failures to identify the diseases are self-limited and neither need nor respond to
causative microorganism and to narrow the antibiotic any of the currently available anti-infective compounds.
spectrum thereafter are common misuses of antibiotics. Thus, antibiotic therapy of at least 90% of infections of
The first consideration in selecting an antibiotic is the upper respiratory tract and many GI infections is
whether it is even indicated, Diagnosis may be masked ineffective(10).Antibiotic therapy too often is given in the
if therapy is started before appropriate cultures are absence of supporting microbiological data. Bacterial
obtained. Antibiotics are potentially toxic, and may cultures and Gram stains of infected material are
encourage selection of resistant microorganisms. Of obtained too infrequently, and, when available, the
course, definitive identification of a bacterial infection results often are overlooked in the selection and
before treatment is initiated often is not possible. In application of drug therapy. Frequent use of drug
the absence of a clear indication, antibiotics often combinations or drugs with broadest spectra is a cover
may be used if disease is severe and it seems likely for diagnostic imprecision(11).
that withholding therapy will cause failure to manage
a severe or life-threatening infection(2,6).For definitive Material and Method
therapy, the course of therapy should be altered to a
more specific and narrow-spectrum antibiotic once an The work is done in Salah aldin Teaching Hospital,
organism and susceptibility have been identified (2,7). cases are collected during January 2017, the samples are
1700 cases of inpatient treated with antibiotics from
Prolonged usage of empirical broad-spectrum a
coverage or multiple antibiotics should be avoided total of 2150 inpatient case.
because it often is unnecessary, is costly, may select
for antibiotic resistance against multiple agents, and The cases are collected from the patients that are
may cause additional unfavorable effects due to the found in the hospital and from the files of the patients
that still found in the hospital. The study involved with
multiple agents. Inappropriately broad coverage often
determining the definite diagnosis, cause of admission,
is continued because satisfactory cultures were not
rational cause for using antibiotics and the duration
obtained before the initiation of therapy or because of
of the treatment.In this study, some parameters are
the misconception that a broad-spectrum regimen is
involved such as: age, duration of treatment, type of the
better than a narrow-spectrum regimen. Although
antibiotics and their dosage forms and changes in the
reluctance to narrow therapy after a favorable initial treatment regimen.
response has occurred is comprehensible, the goal
should be to use the most selectively active drug that
Results and Discussion
produces the least unfavorable effects, which includes
unfavorable effects on normal host flora(8). The Centers We have seven major types of antibiotics (AB) that
for Disease Control and Prevention (CDC) has outlined are always used in the wards of Salah Aldin Teaching
a series of steps to reduce antibiotic resistance, includingHospital (STH), these are Cephalosporins, penicillins,
proper use of vaccination, thoughtful and proper use Metronidazole, amino-glycosides, quinolones,
of indwelling catheters, early involvement of infectious glycopeptides and macrolides respectively, and other
disease experts, antibiotics are used rarely. In this study, the type of
antibiotics used can be shown by table (1).
Table 1: the use of antibiotics (AB )in the investigated cases
Types of antibiotics In the whole wards of STH in Pediatric Wards Percentage % (total 1700 cases)
Penicillins 524 199 30.8%
Cephalosporins 1267 482 74.5%
Amino-Glycosides 137 54 8%
Conted…
Metronidazole 618 235 36.3%
Glycopeptide antibiotics 90 35 5.2%
Quinolones 78 31 4.6%
Macrolides 47 17 2.7%

Note: some patients received more than one antibiotic.

We found that from 2150 inpatient cases in the 5 wards of STH, 1700 cases were treated with AB and as shown
by the table above; the most commonly used AB is cephalosporins and exactly the 3rd generation cephalosporin.
Which is important to say that between these 1700 cases, we did not find any test for culture and sensitivity neither
we find a gram stain or any differential tests for microbial growth. Also about 99% of the used AB in STH are of
low quality which increases the duration of treatment, risks on the patient, and the risk of AB resistant.The total
cost was 23929$ for the all antibiotics had been spent as registered in the pharmacy books and case sheets of the
hospital,6194$ from the total cost for antibiotics were used by pediatric ward only.

Figure 1: The use of AB for chest infections in the pediatric ward

Two- hundred seventy one cases in the pediatric ward were treated with AB for chest infection. As we can see
from the figure (1), 1331 ampiclox vials had been dispensed for those case, 984 cefotaxime 0.5g vials, 234
ampicillin
0.5g vials, 354 ceftriaxone vials, 184 gentamicin 20 mg amp, and 178 vials of vancomycin vials. This enormous
amounts from AB dispensed for 271 cases to treat chest infections and the duration ranges from 2 days to 7 days
and we already know that 90% of these infections are viral in nature as documented in many clinical
references(11,12,13)

The cost of this irrational use is about 3066$.

Figure 2: The use of AB for treating GE in the pediatric ward

Cases in the pediatric ward were treated with AB for Gastroenteritis (GE). Figure (2) reveals the total no. AB
used for these cases.As we can see from the figure above, 706 cefotaxime 0.5g vial, 268 ampicillin vials, 215
ceftriaxone 0.5g vials, 374 ampiclox vials, 182 metronidazole bottles, and 80 vancomycin 0.5g vials were used in
patients with GE. While almost references of medicine and clinical pharmacology document the fact that AB in GE
will decrease the course of healing by not more than 1 day also that most of cases are viral in nature (8) (this agreed
with Davidson’s principles & practice 20th edition). The cost of this irrational use is about 1635 $.

Figure 3: The use of AB for nosocomial prophylaxis in the pediatric ward

In the pediatric ward about 3.71 cases were received AB for nosocomial prophylaxis as shown in fig.(3), 473
cefotaxime vials, 183 ceftriaxone 0.5g vials, 121 ampicillin 0.5 g vials, 381 ampiclox vials, 37 gentamicin 20 mg
amp, and 8 vancomycin vials were used for patients to prevent nosocomial infection.The chief complaints of these
cases were anemia, blood transfusion, bone marrow aspiration, poor feeding, etc…..

Nosocomial AB prophylaxis should be used more cautiously with regarding culture and sensitivity tests.The cost
of this use was about 821$

Figure 4: The use of AB in the pediatric ward for neonatal jaundice and post neonatal jaundice

Thirty -six cases in the pediatric ward were complaining from neonatal jaundice and post neonatal jaundice and
received AB. Figure 4 reveals the total no. of AB used for these cases, As we can see from this figure, for only 36
cases, 97 ampicillin vials, 34 cefotaxime vials, 9 ceftriaxone vials (contra-indicated in neonatal jaundice(6) and this
agreed with the British National formulary BNF), 61 ampiclox vials, 90 gentamicin 20 mg amp and 6 vancomycin
0.5g vials were used for this group of patients. While no specific indications were found for these cases and no
support from the references for this use. Most of these cases not need AB therapy just phototherapy and we
recommend that the patients who need AB should be selected. The cost was about 169$.
Figure 5: The use of AB for patients with febrile convulsion

Fourteen cases of febrile convulsions were treated with AB in the pediatric ward for the underlying cause. Figure
-5 show reveals the total no. AB used for this group.As we can see from this figure, cefotaxime and ampiclox vials
are the most commonly used also vancomycin vial found a place in these groups. Most of febrile illnesses caused by
viral infections (6) (this agreed with reference 7,14) and the cost of this use is about 148$.

16 cases were treated with AB for croup( acute viral infection of the upper airway (1)).

Figure 6: The use of AB for patients with croup in the pediatric ward

Figure 6 reveals the total no. AB used for these cases.As we can see from the figure below, for 16 cases with
croup, 71 cefotaxime 0.5g vials, and 62 ceftriaxone 0.5g vial were used for these cases which most of them do not
need AB treatment. The total cost for this use is about 45$.

Figure 7: The use of AB for patients with kerosene poisoning

Five cases of kerosene poisoning in the pediatric group were treated with AB from the 1st day of admission.
Figure 7 reveals the total no. AB used for these cases.AB in kerosene poisoning should not be used only if
secondary bacterial infection occurs (this agreed with Karen etal.,2007)(6) The cost of this use is about 33$.

Figure 8: The use of AB in the pediatric for UTI

Nine cases were treated with AB for UTI in the pediatric ward. Figure 8 reveals the total no. AB used for this
group. The total cost for this use is about 40$

Figure 9: The use of AB for patients with septicemia in the pediatric ward

Two cases of septicemia were treated with AB. Also without test of culture and sensitivity. Total cost 42$

Figure 10: Chart about the use of AB for meningitis in the pediatric ward
Four cases were treated with AB for meningitis in 3. Mary A.K Pharm D, Lioyd Y.Y Pharm D, Brian
the pediatric ward. Figure 10, reveals the total no. AB K.Alldredge pharmD, Robin L. Corelli PharmD,
used for this group. The cost of this use is about 195$. B.Joseph Guglielmo PharmD, Wayne
PharmD,
A.Kradjan BCPS. Applied Therapeutics:the clinical
As we can see from this chart, 104 ceftriaxone use of drugs. 9th ed. United states: 2009. P8-24.
0.5 with 108 chloramphenicl (1 g ) vials were
g vials
used 4. Maie A.C, PHARMD, FCCP, FASHP,
for 4 patients and the duration were not less than 10 G.W, PHARMD, FASHP, FCCP,
BARBARA
days. This reveals also how bad is the quality of these BCPP,
TERRY L.S, PHARMD, FCCP, FASHP,
AB used in the hospital, while the use of top quality AB BCPS.
Pharmacotherapy principles & practice. 1st ed.
will decrease the cost, risk on the patient and risks of AB Newyork :2008. P1019-1030.
resistant (10,15,16).
5. Sweetman S C, Martinadale. The complete
Drug Reference. Journal of the medical library
Conclusions association. 2007(2):75-76.
1. The antibacterial agents are used in the wards of 6. Karen Baxter, Kate Towers, Jssica A.Forrest,
the hospital roughly, without differential tests and Kristina fowlie, Heenaben patel, Angela M,
without any respect to the guidelines of judicious GMC Fariane. BNF(British National Formulary).
AB use to decrease the resistant. Britain:2007.P438.
7. Richard E.Behrman, Robert M.Kliegman, Hal
2. Cephalosporins are the most commonly used AB
B.Jenson. Nelson Textbook of Pediatrics. 17th ed.
in all the five wards of STH and namely the 3rd
United state:2004. P903.
generation cefotaxime and ceftriaxone.
8. Nicholas A.B, Nicki R.C, Brain R.W, John A.A.
3. The total cost of using AB in STH for only Davidsons Principles &Practice of medicine. 20 th
one ed. China:2006.P75.
month is about 23929 $, 6194$ in pediatrics.
9. Borg M, Cookson B, Zarb P, Scicluna E.
4. The enormous amounts of AB used in STH Antibiotic resistance surveillance and control in
can the Mediterranean. Region. 2009, 3(9):654-659.
easily lead to serious problems of resistant 10. Canon Mac Dougall, Jason Gallagher. Antibiotic
infections Simplified. 2nd ed. 2011:P15-17.
5. Huge amounts of AB dispensed for chest 11. van de Sande-Bruinsma N, Grundmann H, Verloo
infections and GE (usually are viral in nature), D, Tiemersma E, Monen J. Antimicrobial drug
also many patients with jaundice, and CRF use and resistance in Europe. Emerg Infect
received AB may be contraindicated to their Dis.
cases. 2008;14:1722–1730.
12. Sabuncu E, David J, Bernède-Bauduin C, Pépin S,
Acknowledgments Leroy M, Boëlle PY,et al. “Significant reduction
We would like to express our great appreciation of antibiotic use in the community after a
to Salah aldin Teaching Hospital, for help me in nationwide campaign in France, 2002-2007”.
collecting the cases of this search. 2009: P1-5.
13. Cassir N, Rolain JM, Brouqui P. A new strategy
Ethical Clearance: From research ethic committee in to fight antimicrobial resistance: the revival of old
Tikrit university/college of medicine antibiotics.2014; 5: 551.
14. Zhanel GG, Lam A, Schweizer F, Thomson K,
Source of Funding: self
Walkty A, Rubinstein E, et al.”Ceftobiprole:
Conflict of Interest: None a review of a broad-spectrum and anti-MRSA
cephalosporin”. American Journal of Clinical
Dermatology.2008; 9 (4): 245–54.
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15. Berger, Dr. Stephen. GIDEON Guide to
1. Philip Thomas Reeves.Antibiotics groups & Antimicrobial Agents. 2014. p 221.
properties. Puplished by John Wiley&Sons: 2012.
16. Dr. Peter M. Wright, Dr. Ian B. Seiple, and
P1-60.
Prof. Dr. Andrew G. Myers. The Evolving Role
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MD,PHD. Goodmans & Gilmans:manual of Discovery. 2014. p2-7.
pharmacology and therapeutics. 12th ed. Newyork:
2011. P1365-1383.
DOI Number: 10.5958/0976-5506.2019.01660.7

Education Conducted By Pharmacist in Improving

Hyperlipidemic Patient Adhearance

Vidia Arlaini Anwar1, Delina Hasan2, Sesilia Andriani Keban3, Yardi Saibi2
1
Stikes Kharisma Persada Pamulang; 2Pharmacy Study Program at UIN Syarif Hidayatullah, Jakarta;
3
Faculty of Pharmacy, Pancasila Univeristy

ABSTRACT
The adhearance is one of the keys for successfulness of drug therapy. Low adherence is often found in long
time drug use, one of them is hyperlipidemic patients. This study aimed to investigate the effect of
pharmacist education intervention on patient compliance and their lipid plasma level. The research design
was quasi- experimental nonequivalent group control and perspective. The study was conducted on
hyperlipidemic at Port of Jakarta hospital. The number of samples was determined by using Krejcie and
Morgan tables which yielded 44 respondents/patients. Compliance is measured by an MMAS
questionnaire. The control and intervention groups were given leaflet containing drug information and
gave the patient the opportunity to ask questions. The results showed that there was no significant
difference in patient characteristics in terms of gender, age, education and dependent (p <0.05) except on
the distance characteristics (p> 0.05). Patient compliance increase in the intervention group differs
significantly from the control group in the second and third periods of measurement (p <0.05) while the
compliance improvement in the control group occurred in the third period of measurement (p <0.05). The
plasma cholesterol level decreases significantly differences between intervention from the control group
at the third measurement (p<0,05). It can be concluded that pharmacists’ education either in the form
of leaflets with verbal explanations or in leaflet alone can improve patient compliance with their
medications where the improvement is faster achieved by pharmacist intervention in the form of a leaflet
with a verbal explanation. Pharmacist education is also able to decrease patient plasma cholesterol level.

Keywords: compliance, pharmacist education, hyperlipidemic

Introduction study respondents obtained 290 people (59.2%)
among
Based on basic health research data 2013 them in a state of hyperlipidemia2.
showed
35.9% of Indonesia’s population aged ≥ 15 years with World Health Organization (WHO) 2013 reported
abnormal cholesterol levels (based on NCEP ATP III, that the highest prevalence of total blood cholesterol
with cholesterol levels ≥ 200 mg/dl), where women were in Europe (54% for both sexes), followed by America
more than men, and cities were more a lot compared to (48% for both sexes). Africa and Southeast Asia have a
the countryside. Some provinces in Indonesia such as low percentage of 22.6% and 29.0% respectively. High
Nangroe Aceh, West Sumatra, Bangka Belitung, and cholesterol is estimated to cause 2.6 million deaths
Riau Islands have a prevalence of hyperlipidemia ≥ (4.5%) and 29.7 million disabilities each year 3.
50% 1. Data from the Double Study of the Faculty of Hyperlipidemic patients include patients who need
Medicine, University of Indonesia (2009) showed that long-term therapy, which usually correlates with low
the results of the measurement of lipid profiles in levels of adherence to drug use as reported in several
490 publications4. One study found that after nine months of
statin therapy, only 56% of patients continued to take
treatment and this percentage continued to decline after
Correspondence Author: the first year5. The level of adherence of patients who
Vidia Arlaini use lipid-lowering drugs on average is 50%, with about
Anwar 2/3 of patients remaining obedient on the first year of
Stikes Kharisma Persada Pamulang treatment6.
Email: [email protected]
724 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 724

These patients need special attention by pharmacists control group and 30 (68.18%) for the intervention
in accordance with pharmaceutical service standards. group. The results of the statistical test showed that
The provision of education or drug information services there were differences in the distribution of the sex
is the obligation of pharmaceutical staff regulated in group of the control group and the intervention but
the decision of the health minister of the Republic of the difference was not significant (p = 0.271> 0.05).
Indonesia number 72MENKES/SK/X/2016. Basal metabolic rates for men are 10 percent higher
than women. Therefore, women tend to convert
Compliance is one of the keys to success in achieving
food into fat more, whereas men tend to
an optimal therapeutic outcome. It is hoped that education convert
food into muscle and reserve energy ready to use.
and counseling by pharmacists can improve patient
Muscles burn more fat than other cells. Because
compliance8–9.
women have fewer muscles, women have a smaller
chance to burn fat.13
Method were female respondents, that is as many as 25
(56.81%) for the
The method used in this study is a quasi-
experimental non-equivalent control on hyperlipidemic
patients who were outpatient at Jakarta Port Hospital
on the period of August - October 2017. Sample were
all populations that met the inclusion criteria: Patients
who came to the pharmacy installation during August -
October 2017; diagnosed with hyperlipidemia in their
medical records and received treatment with
antihyperlipidemic drugs, patients with complete and
clearly legible medical records.

The technique of getting samples is by consecutive

sampling. The number of samples was determined by
Krejcie and Morgan11. Samples were divided into 2
groups of 44 people each; the first group was the control
group, while the second group was the intervention
group. To enter the sample into the control or
intervention group was determined by multiples of 5, ie
the first 5 patients were included in the control group
while the next 5 patients were included in the
intervention group, and so on until the number of the
two sample groups was sufficient. The research
instrument is a compliance questionnaire refers to the
MMAS 12 method.

Result and Discusion

A. Sosio-Demographic Respondent Characteristics:
The socio-demographic characteristics of the
respondents in the control group and the
intervention group included gender, age, education,
the distance of house (residence) and dependents
(costs) as shown in table 1. It can be seen that
based on sex category, the majority of respondents
in the control group and the intervention group
725 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 725
Based on the age category, most respondents in
the control group and intervention group were 35
(79.55%) for the control group and 29 (65.91%)
for the intervention group. The results of the
statistical test showed that there were differences
in the distribution of the control group and
intervention age categories but these differences
were not significant (p = 0.151> 0.05). The
number of hyperlipidemic patients at >55 years is
far greater than the age group below. The risk of
hyperlipidemia increases with age. The weakness
of the body is known to increase with age and
predominantly accumulates in the area around
the abdomen. LDL levels decrease with age and
conversely LDL levels increase14.
Based on the education category, the majority of
respondents in the control group and intervention
group were respondents with high school
education, which were 25 (56.82%) for the control
group and 24 (54.55%) for the intervention group.
The statistical test results showed that there was a
difference in the distribution of the control group
and intervention education categories but the
difference was not significant (p = 0.612> 0.05).
The higher the level of education of a person,
the higher his awareness of efforts to maintain
his health. This may be the cause of the highest
number of patients at the high school level.
Based on the category of distance house
(residence) with the hospital, the majority of
respondents in the control group were long
distance as much as
8 (18.18%) and the most intervention group
was
close distance as many as 36 (81.82%).
Table 1 : Distribution of Socio-Demographic Characteristics of Respondents in the Control Group
Group
Variable p
Control Percentage (%) Intervention Percentage (%)
Gender
a. Male 19 43,18 14 31,82
b. Female 25 56,82 30 68,18 0,271
total 44 100,00 44 100,00
Age
a. · 36 - 45 tahun 3 6,81 4 9,09
b. · 46 - 55 tahun 6 13,63 11 25,00
c. · 56 - 65 tahun 19 43,18 19 43,18 0,151
d. · > 65 tahun 16 36,36 10 27,72
total 44 100,00 44 100,00
Education
Elementary school/
a. 15 34,09 13 29,55
Junior high school
b. Senior high school 25 56,82 24 54,55 0,612
c. PT 4 9,09 7 15,91
total 44 100,00 44 100,00
Distance
a. Near (1 - 10 km) 31 70,45 36 81,82
b. Medium (11 - 20 km) 5 11,36 4 9,09
0,02
c. Far (21 - 30 km) 8 18,18 4 9,09
Total 44 100,00 44 100,00
Insurance
a. Insurance 40 90,91 39 88,64
b. Cash 4 9,09 5 11,36 0,725
Total 44 100,00 44 100,00

The results of the statistical test showed that there were differences in the distribution of dependents in
the
control group and intervention respondents, but these differences were not significant (p = 0.725> 0.05).
B. Description of Respondent’s Compliance

Table 2: Percentage of patients based on the level of compliance per period between two

Level of Period 1 Period 2 Period 3

No. p p p
compliance Control Intervention Control Intervention Control Intervention
1. Low 90,91 81,82 84,09 63,64 52,27 0,00
2. Medium 9,09 11,36 0.188 15,91 29,55 0,023 47,73 34,09 0,000
3. High 0,00 6,82 0,00 6,82 0,00 65,91
The question of the respondent’s compliance as of 90.91% for the control group and 81.82% for the
many as eight questions. Table 2 shows the level of intervention group. The percentage of high adherence
compliance of the respondents of the two groups for each level categories is 0% for the control group and 6.82%
period. The highest level of compliance of the for the intervention group. Differences in compliance
respondents in the two groups was respondents with a between two groups of respondents were statistically
low level of adherence
tested with the Mann Whitney test and the results as The results of this research indicate that pharmacist
shown in table 2. It can be seen that in the first period education affects the compliance of hyperlipidemic
there were no significant differences in adherence patients in taking cholesterol drugs. Interventions carried
between the two groups of respondents indicated by the out by pharmacists in the form of consultations with
significance value of 0.188 (p value> 0, 05). In the patients where the pharmacist discusses the management
second and third periods of measurement, statistical of medication that will be undertaken by the patient
analysis showed that there were significant differences in including lifestyle changes. Pharmacists also provide
adherence between the two groups as indicated by a patients with some material related to the treatment of
significance value smaller than 0.05. This means that in patients 21.
the second and third period, verbal education conducted
by pharmacists has been able to have an effect on The pharmacist’s intervention in the form of
respondents’ compliance in using drugs prescribed by education carried out at the beginning of the patient
doctors. came to the pharmacy to redeem their medication,
then performed again when the patient came back. At
Low compliance is a problem in the long-term two repeated measurements, there was an increase in
treatment of patients for chronic non-infectious diseases compliance in intervention patients 23
and for long-term infectious diseases such as
tuberculosis and HIV-AIDs. Patients of this group need Effects of interventions carried out by pharmacists as
to get priority for health workers including pharmacists outlined previously are summarized in the following table:
in the form of counseling 15.

Table 3: Percentage of patients based on changes in the level of compliance per period Intervention group
Level of Intervention (2-1) Intervention (3-2)
No. Period 1 Period 2 p Period 2 Period 3 p
compliance
1. low 81,82 63,64 63,64 0,00
2. medium 11,36 29,55 0,003 29,55 34,09 0,000
3. high 6,82 6,82 6,82 65,91
Table 3 shows changes in adherence and statistical From the statistical test as seen in table 4, the change
test results to see the differences in the intervention in adherence in the second period of measurement was
group. Total of patients with high levels of adherence is not significant which was indicated by a significance
greatly increased. value of
0.083 (> 0.05). Changes in adherence in the third period
The statistical test used is a paired sample t-test. The
of measurement were seen to be significant in the third
results of this statistical test are presented in table 5.6. It
period of measurement marked by a p-value <0.05
can be seen in table 5.6 that for the pharmacist education
(0,000). This finding is in line with the report in a
intervention group it has shown the effect of the second
literature review which explains that the intervention
period of measurement indicated by p <0.05.
provided is only in the form of written information that is
not very efficient if given to
patients who receive treatment for the long term25.
Table 4 : Percentage of patients based on changes in the period of meeting rates Control group

Level of Control (2-1) Control (3-2)

No. p p
compliance Period 1 Period 2 Period 2 Period 3
1. Low 90,91 84,09 84,09 52,27
2. Medium 9,09 15,91 0,083 15,91 47,73 0,000
3. High 0,00 0,00 0,00 0,00
Conclusion was indicated by a significant difference between the
Pharmacist education (leaflet and verbal) can intervention groups to the control group (p <0.05).
improve patient adherence in using the drug in the Giving leaflets that contain drug information requires
first and second months after the intervention, which a longer time to improve patient compliance with
drug
use, which is indicated by a significant difference in the Clin Pract. 2008;62(1):76-87. doi:10.1111/j.1742-
compliance of the control group in the second month of 1241.2007.01630.x.
measurement (p <0.05).
7. The Republic of Indonesia. Minister of Health
Regulation Number 72 of 2016 concerning
Suggestions Standard of Pharmaceutical Services at Hospitals;
2016: 1-73.
Education for hyperlipidemic patients should be
continued and even intensified. It is necessary to measure 8. Anggraini R, Wahyono D, Rahmawati F,
plasma lipid levels in addition to total cholesterol levels Gunawan C. EFFECT OF APPLICATION
with the consequence of increasing research costs. EDUCATION ON THE COMPLIANCE OF
ANTIRETROVIRAL MEDICINE (ARV) IN
Grateful Greeting HIV/AIDS PATIENTS. 5th Urecol Proceeding.
2017; (February): 1450-1456.
Thank you to those who have helped this research
9. Yosi Febrianti; Satibi; Rina Handayani.
Conflict of Interest: None The Influence of Pharmacist Counseling on
Compliance Levels and Therapeutic Results of
Ethical Clearance: From ethical committee at UIN Outpatient Hypertension Patients in the Internal
Syarif Hidayatullah Medicine Polyclinic. J Manaj and Farm Services.
2013; 3 (4): 311-317
Source of Funding: Self
10. Dewanti SW, Andrajati R, Supardi S. Effect
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Indonesia. I. PB. Perkeni; 2015 MORGAN. Determining Sample Size for
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index.html 1 sur. HJ. Predictive validity of a medication adherence
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Lipid-Lowering Medication. Ochsner J. R, Bogardus C, Ravussin E. Lower sedentary
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DOI Number:10.5958/0976-5506.2019.01661.9

The Effect of Exercise Technique Altering with Use

Heavyweight Rackets in the Development of Concentration
(Sodium, Potassium) in the Blood and Smash Skill for Player’s
Badminton

Wissam Salah Abdul Hussein1, Abeer Ali Hussein1, Ebtighaa Mohammed Qasim1
1
University of Kerbala/The College of Physical Education and Sports Sciences, Iraq

ABSTRACT
The skill of beating is one of the most important offensive skills in the game of badminton, through which
the player can decide the point in his favor, and given the diversity of the use of skills at one point and
the speed of the large brush requires us as researchers to find the best technique to develop this skill, so
researchers used The method of exercise altering dimensions and trends and different altitudes in addition
to the use of different weights and weights of some of them are heavy and some of them are lighter, and
researchers try to know this method on the concentration of functional alterings in blood and whether there
was a burden and effort on the muscle.
The aim of the research was to prepare a special exercise in the style of the altering exercise and using
burdens loaded with badminton. To study the effect of the altering exercise method using the weight-laden
binders in the concentration of sodium (potassium) in the blood and to develop the skill of smash of the
player’s badminton. The search for the altering exercise method in the overloaded bats has a positive effect
on the concentration of sodium (potassium) badminton. The researchers used the experimental approach to
design a single group with pre and post testing in order to suit the nature of the problem and achieve the
research objectives. The sample of the research represented the entire research community and they are
players of the province of Babylon for the season 2018 - 2019 and the number of (4) players, which means
researchers used the method of comprehensive inventory of all members of the community.
The most important conclusion was that the altering exercise technique helped to develop the crushing
skill of the feather. There was a marked improvement in the concentration of salts of blood (sodium and
potassium), but within the natural information in the upper direction due to the use of exercise loads in
the experimental group. The most important recommendations are the need to pay attention to the training
altering during the educational units because it is best to deal with the skills of badminton, which falls
within the open circuit system. And the need to use different and varied exercise technique commensurate
with the skills required to perform.

Keywords: exercise technique altering, sodium, potassium and blood.

Introduction need to know the teacher and the trainer for more than
one of the technique of exercise because otherwise it
The expansion of the technique of learning motor
remains in the ability to deal with players is very limited
skills invites researchers to carefully choose the
so the use of more than a method of learning gives the
appropriate method for the conditions of the learning
opportunity for the coach and player to upgrade the
environment, such as the type of effectiveness, age, level
educational process.1
of scientific and educational sample, and their physical
and skill preparation, and that developing the abilities of We have been able to develop our concepts of the
the players depends heavily on how they interact with training process as a competitive trend in the field of
and respond to the educational method followed. sports and to take strides towards the construction
The of
730 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 730

valuable scientific concepts to impose Scientific and they are players of the province of Babylon for the
Interest.1 season 2018 - 2019 and the number of (4) players, which
Since badminton is an individual game practiced by both means researchers used the method of comprehensive
sexes and most of its skills fall under the open circuit inventory of all members of the community.
system, during which the development of the skill level
of the learner.2 Means, Tools and Devices Used:
z A terrace at the height of 1 m (2) homemade
The skill of smash is one of the most important
offensive skills in the game of badminton, through which z Badminton court number (2) - Number of (10)
the player can decide the point in his favor, and given homemade
the diversity of the use of skills at one point and the z Electronic Stopwatch (2) Chinese Made
speed of the large brush requires us as researchers to
find the best technique to develop this skill, so z Badminton Rackets No. (14) type (Yonex)
researchers used The method of the altering exercise z Badminton balls (40) Plastic and natural feathers
dimensions and trends and heights of various and (Yonex)
different in addition to the use of different weights and
z String Number (15) Type (impact) - Jumping ropes
weights of some of them are heavy and some of them
Number (10) Type (Yonex)
are lighter, and researchers try to know the effect of this
method on the concentration of functional altering in z Plastic columns at heights (cm -170 - 180 cm - 2 m)
blood and was there burden and effort on the muscle.3 Number (2) for each measurement
z Homemade cords with length (10 m) - Loaded
Therefore, the importance of research is to benefit
rackets - Complete laboratory tools for the purpose
from the technique of altering exercise using different
of drawing blood from the sample - Loaded rackets
weights and their effect on the concentration of salts
(sodium - potassium) in the blood and skill smash for Tests used and their descriptions:
the players badminton.
Test the crushing skill of the front crushing:
4
Research Aims:
1. Prepare exercises in a modified exercise Purpose of the test: measure the accuracy of the
method crushing skill of the front crushing
and using burdock burdens.
Required tools: feather benders, natural feathers,
2. To identify the effect of the method of the altering additional lists (213cm) height, rubber rope, data
exercise using burdens in the concentration registration form, feather court designed with test
(sodium - potassium) in the blood and develop the design. As in Figure (1).
skill of smash of the players badminton.
Performance Description: The player stands in the
Hypothesis: designated place (Χ) and sends the badminton sent to
1. The method of exercise altering with use him from an interview area ( ) With a strong crushing
heavyweight rackets concentration (sodium, blow trying to drop it in the top-level area provided that
potassium) in the blood and develop the skill of the feather passes over the net and from under the rope
smash of the players badminton. behind the grid at a distance of 60 cm and the height of
(213cm) and the player performs (10) attempts with the
observation of the force of the strike.
Research Methodology and Field Procedures
Performance Evaluation:
Research Methodology: The researchers used the
experimental approach to design a single group with pre 1. The degree is given according to the place of fall
and post testing in order to suit the nature of the problem of the feather.
and achieve the research objectives. 2. If the feathers do not cross over the net and under
the rope or fall outside the designated areas, they
Search Community and Sample: The sample of
shall be given zero.
the
research represented the entire research community
3. Feather that lies on the line between the two the players and the test of the overwhelming beating of
regions given the highest degree the feather.
4. Degrees Divided by Regions (1-2-3-4-5). Special exercises used in research: Through the
5. The final grade is the total of the degrees of experience of field researchers in the field of badminton
attempts (10) which is (50) degree. and relying on Arab and foreign sources, I performed
various exercises (Appendix 1). These exercises were
organized to suit the members of the sample and the
level of training. Based on the principle of changing the
parameters of one skill, and height and distances using
a racket different from the weight of the real racket, and
took part of the main section and the rate of (20) minutes
and two units per week. The course was divided into (9)
training units.
Figure 1: Shows the layout of the badminton court Posttests: The researchers carried out the post tests
to test the overwhelming frontal impact on
Test of sodium and potassium: It was agreed with a 1/3/2019 in the closed hall in the district of Mahaweel,
scientific laboratory licensed health to take a sample of the province of Babel. Blood samples were taken for the
blood for the players of the province for the purpose of players and the test was carried out by the crushing
conducting the necessary analysis to know the ratios of blow. Under the same circumstances as the pretest.
sodium and potassium.
Results
Pre Tests: The researchers conducted the pretests
on Presenting the results of the pre and post-test tests
1/2/2019 in the closed hall in the district of of the sodium and potassium test group and the crushing
Mahaweel batting skill.
- Governor of Babel, and blood samples were taken for

Table 1: Show calculate the values of the mean, the standard deviation, and the calculated Wilcoxon values
for the tests pre and post and experimental group
Pretest Posttest Wilcoxon Level of Type of
Skill Units Mean SD Mean SD values significance significance
Sodium test Mall 140 2.3 149 3.11 2.21 0.02 Sig.
Potassium test Mall 4.5 0.41 5 2.70 2.22 0.03 Sig.
Front smash Grade 21 3.11 29.4 4.99 2.21 0.01 Sig.
Sample size = 4 below the level of significance (0.05).
Table (1) shows that there are statistically significant differences, since the values of the significance level were
less than the value of the significance level (0.05). This indicates that there are differences and for the benefit of the
post-test. This is due to the exercise method used by the researchers.

Figure 2: Show the differences between the computational circles and the post deviations of the pre and post
tests
Discussions 3. There is a marked improvement in the
concentration of salts of the blood (sodium and
The researchers attribute the difference between the
potassium), but within the natural information in
pre-test and the post-test of the experimental group to
the upper direction as a result of the use of heavy
the exercises used in the training modules and the use of
weights in the exercise of the experimental group.
training technique in accordance with the learned skill
type. The use of the exercises prepared for the skills Ethical Clearance: Taken from University of Kerbala
studied and applied in the altering exercise method.
The explanation, presentation, guidance, instructions Source of Funding: Self
and feedback were The great effect on the development
Conflict of Interest: None
of the experimental group in the post-test, where the
correct organization of the exercises used, which
took all the skill forms and different parameters and REFERENCES
different (power-speed-distance-time) Experimental 1. Zakia I. A. Et al.: Methods of Teaching in
group members have developed a variety of mobility Physical Education, C1, Edit.1, Alexandria,
programs for one skill, increasing the chances of success Library of Artistic Radiation, 2000.
of the skill when performing on the field. The teacher or
2. Samar K. N.:Effect of the use of certain weights
trainer is designed for the learning environment, which
in the development of muscle strength and some
creates educational systems, achieves the goals of the
functional alterings in blood in tennis, Master
educational unit and prepares educational situations.5
Thesis, University of Diyala, 2005, p. 2.
Wrisberg (2000) points out that the use of motor forms
for one skill develops the generalized motor program 3. Mazen H. K.: Effect of presentation and direct
and improves the player’s performance despite different and deferred implementation in learning some
measures for the program itself. The development of badminton skills and moving its impact to some
the locomotor program is enhanced when the player tennis skills, PhD thesis, University of Babylon,
exercises wide variations of movements and the same Faculty of Physical Education, 2008.
class of movement.6 4. Mohamed N. R.: The Foundational Statistics in
The increase in the sodium and potassium altering the Sciences of Physical Education and Sports, 1,
due to their direct association with the increase of Cairo: Arab Thought House, 2003.
muscular and nervous activity due to physical exertion 5. Moqdad Z.: the relationship of the concentration
(effort of the game), and the increase in the of the most important mineral salts and the speed
concentration of mineral salts (sodium, potassium) due of motor response accurately some of the skills
to the impact of physical exertion, which was of badminton for young players, Master Thesis,
characterized by the extreme intensity that the player University of Qadisiyah, 2013, p. 58.
during the game and work Functional devices lead to
6. Mohamed H. A. and Abuela A. F.: physiology of
the balance of mineral salts in the body so this is an
sports training, Cairo, Dar al-Fikr al-Arabi, 1988,
increase within normal limits. 7 “The permeability of
p. 413.
metal ions leads to an imbalance in the distribution of
mineral salts on both sides of the fibroblast membrane 7. Sam S. A.: Badminton between practice and
causing muscle contractions “. 8 competition, Amman, Dar Radwan for printing
and publishing, 2013.
Conclusions 8. Richard A. S.: Craig A. Weisberg. Motor
1. The technique of the altering exercise helped Learning and Performance, Second edition,
to Human Kinetics, 2008.
develop the skill of beating overwhelming
9. Alsayigh HA, Athab NA, Firas M. Journal
feather.
of Global Pharma Technology The Study of
2. The use of heavy speculators helped increase the Electrical Activity of the Triceps Brachia Muscle
accuracy and strength for the overwhelming blow
to the plane
according to the Chemical Changes of Water Loss of Physical Education and Sports Sciences.
during Spike in Volleyball. 2017;57–62. 2018;928–35.
10. Al-mashhadi RAA. The Impact of the Plan and 11. Alsayigh HA, Athab NA. The Study of Rectus
PDEODE Strategies in Developing Awareness of Femoris Activity after Knee Joint Rehabilitation.
Cognitive Processes and Reducing Psychological 2016;9(9):360–5.
Pollution Among Students of the Faculty
DOI Number:10.5958/0976-5506.2019.01662.0

Evaluate the Level of Application of Sports Marketing

Practices for the First Iraqi Football Clubs

Yaseen Ali Khalaf1, Ibrahim Younis Waga1

1
University of Anbar, College of Physical Education and Sport Science, Iraq

ABSTRACT
The present paper aims to identify the role of sports marketing in developing the performance of the
administrative corporations of the Iraqi football Premier League clubs. A survey descriptive method has
been used due to its relevance to the research problem and aims. The sample is composed of members of
the administrative corporations of the Iraqi football Premier League clubs for the 2017 - 2018 season. The
total sample consisted of (101) members elicited from 19 sports clubs; it was selected in a deliberate
manner, as it is representative for the whole sample according to three variables (job status, academic
qualification, and years of experience in administrative work). It was found that the measure of sports
marketing was accepted and expressed in terms of sports marketing practices from the point of view of
employees in the football Premier League clubs, and that all staff members have a positive attitude
towards sports marketing. It was recommended that it is needful to benefit from the scale of sports
marketing and apply it to different samples and raise the grants offered to sports clubs to carry out their
various activities and achieve their marketing objectives and to conduct studies and research in the field
of marketing sports in Iraq and its novelty and modernity of this field in Iraqi sports sector.

Keywords: Evaluation, sports marketing and practices.

Introduction sports from the point of view of the members of the
governing corporations of the Iraqi football Premier
Sports marketing has been considered as one of the
League clubs via evaluating the application of sports
main areas on which sports institutions in the world rely.
marketing practices to reflect the reality in the field
Hence, it is considered as the most successful option
of marketing and the need to develop and identify the
able to ensure the sustainability of the economic
imbalances to increase the administrative awareness
recovery that can cover sports activities as well as the
within the sports institutions to ensure the development
financial profit that contributing to the growth and
of sources of financial financing facilities for the
development of these institutions in line with the goal.
marketing process. There is lack of sports marketing
Therefore, this field has witnessed a gradual
plans within the sports institutions due to the difficulties
development and became more widespread and
and financial crises that affect sports marketing plans
diversified in the present time as it included various
within the sports institutions. They prevent most of the
methods, such as marketing of advertising rights,
Premier League clubs in Iraqi football from
television marketing and marketing of tournaments and
implementing their programs and activities planned in
players and as well as the provision of internal and
the required form. Due to the lack of significant financial
external services to the consumer represented by the
resources in this area because sports marketing is still
public. This area has become an administrative and
new in Iraq, such institutions do not depend on sports
economic system that has imposed itself through
marketing to improve their resources and annual
positive financial returns. Therefore,
financial plans and do not move consistently. In
‘marketing is an art of successful management process,
addition, sports clubs rely directly on government grants
which affects the society in general and the sports
offered by the Ministry of Youth and Sports and the
community in particular’.1
Iraqi Olympic Committee to cover the annual activities,
The significance of the research stems from its role which call to the level of ambition, in addition to some
in highlighting the reality of the process of donations from businessmen.
marketing
735 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 735

Conted…
Research Aims: To know the role of sports marketing and Conted…
its importance in developing the performance of the
15. Naft Maysan 5
governing bodies of the Premier League football clubs in
16. Al-Bahri 5
Iraq.
17. Al-Samawa 5
18. Al-Diwaniya 5
Research Methodology and Fieldwork Procedures 19. Karbala’a 5
Total 101
Research methodology: The researchers used
descriptive method of survey to suit the nature of the Measuring Tool: In order to identify the status of sports
problem and achieve the research objective. marketing in the Iraqi football Premier League for the
(2017 - 2018) season, the researchers used the Sports
Sample and its design: The sample included 101
Marketing Scale (Yaseen Ali Khalaf 2018) applied to
members of the administrative corporations from
the Iraqi environment consisting of seven areas and 62
19 Premier League football clubs for the 2017-2018
statements. The correcting process of this scale is based
season, which was divided into and the sample was
on the five-way Likert method of alternatives (fully
selected by the deliberate search as in Table (1) as they
agree, agree, neutral, disagree, do not agree).2
represent all categories of the sample according to the
variable (job status, qualification, years of experience in Applying the Scale: The scale was applied to the
administrative work). research sample composed of 101 participants of the
administrative corporations; the scale was distributed for
Table 1: Total research community the period from 1/7/2018 to 2/8/2018. After completing
the implementation steps, the researchers collected
S. No. Iraqi Football Premier league No. the data and arranged it in tables pending statistical
1. Al-Quwa Al-Jawiya 6 processes to complete the research aim.
2. Al-Quwa Al-Jawiya 6
3. Al-Talaba 6 Data Analysis and Discussion
4. Al-Shorta 6 The researchers relied on the percentages shown in
5. Al-Kahrabaa 6 table (2) to interpret the results of participants’
6. Al-Naft 6 responses.
7. Amanat Baghdad 5
Table 2: Percentages and levels of the scale fields
8. Al-Hussein 5
9. Al-Hudood 5 S. No. Category
10. Al-Sinaat Al-Kahrabaiya 5 1. 80 % and above
11. Al-Naft 5 2. 70% - 79%
12. Al-Minaa 5 3. 60% - 69%
13. Naft Al-Junoob 5 4. 50% - 59%
14. Naft Al-Wasat 5 5. Below 50%
Participants’ responses for all fields of the scale by functional variable:

Table 3: Show the mean, standard deviations and percentages of the scale Variabless by function variable
Variables Chair Vice President Secretary Member
Percentage

SD
SD
Percentage

Percentage
Mean

Mean

SD
Mean

Percentage
SD

Mean

Laws and
Regulations 42.19 2.43 84.37 40.18 3.25 80.35 41.25 4.25 82.49 42.19 4.69 84.37
(Legal Dimension
Administrative
35.93 2.47 79.85 34.57 2.35 76.81 33.56 2.34 74.58 34.57 3.48 76.81
dimension
The economic
dimension of 33.24 2.34 83.09 32.46 4.32 81.14 32.15 3.15 80.36 32.15 2.01 80.36
sports marketing
The technical
dimension of 36.29 2.77 80.64 34.69 2.34 77.08 33.65 5.42 74.78 36.29 4.354 80.64
sports marketing
Technical
(technological)
26.58 1.44 75.92 24.36 2.45 69.58 25.35 4.21 69.56 22.48 1.234 64.22
dimension of
sports marketing
The Social)
dimension of 37.44 2.34 83.2 36.57 4.24 81.26 35.65 3.21 79.21 36.25 4.356 80.54
sports marketing
The media
dimension of 40.61 2.13 80.12 38.36 3.37 76.71 38.78 3.48 77.56 44.36 5.31 88.71
sports marketing
Total 251.7 15.92 81.20 241.2 22.32 77.79 240.4 26.06 77.54 248.3 25.44 80.08
Level Very high High High Very high
Participants’ responses to all areas of the scale by positive attitude and full awareness towards sports
function variable: The results of the tables (3) show marketing and its importance, because of the material
that the total score of the responses of the sample and moral support that help in developing the sports
members for all the fields of the scale according to the movement of the Premier League football clubs in Iraq.
variable of the functional status were close despite the They go in line with Mohamed Sherif’s (2004) study,
differences in their positions. The variable (head) was in which has been one of the most important findings of
the lead with (81.20%) categorised as very high. The the study, in that the concept and importance of sports
marketing for the council members of the boards of
variable (member) came in the second position with a
sports clubs was a positive concept, as they all
percentage of (80.08%) and a very high rating. The
understand this concept and important role in the
variable (vice president) occupied the third position with development of sports.3
(77.79%) and a high rate. Finally, the variable
(secretary) came in the last position by percentage Huda Hassan Al-Khaja’s (2000) study showed that
(77.54%) with a high rating. the weakness of the level of sports marketing can be
ascribed to the fact that the sponsor companies do not
These results indicate that all participants of the provide adequate financial support for sports clubs as
application sample in the functional variable had a well as fear of most businessmen to invest in sports.4

Participants’ responses on all fields of the scale according to the variable of the scientific qualification

Table 4: Show the mean, standard deviations and percentages of the scale fields by scientific qualification

Diploma and below Bachelor Master and Phd

Variables
Mean SD Percentage Mean SD Percentage Mean SD Percentage
Laws and Regulations
39.56 2.35 79.13 39.25 2.3 78.50 43.55 5.32 87.09
(Legal Dimension
Administrative
33.37 3.65 74.14 33.45 2.31 74.33 33.37 3.37 74.14
dimension
The economic dimension
30.32 1.23 75.80 31.25 1.25 78.11 32.65 2.310 81.62
of sports marketing
Conted…
The technical
dimension of sports 40.26 4.32 89.47 37.36 5.34 83.01 37.36 2.021 83.01
marketing
Technical (technological)
dimension of sports 29.33 2.35 83.78 26.58 2.35 75.92 28.35 1.004 81.01
marketing
The Social) dimension
39.35 3.21 87.45 36.25 3.001 80.54 33.24 3.47 73.85
of sports marketing
The media dimension
41.12 2.31 82.24 41.12 4.31 82.24 42.21 5.321 84.42
of sports marketing
Total 253.32 19.43 81.71 245.25 20.88 79.11 250.72 22.812 80.87
Level Very high High Very high
Participants’ responses on all fields of the scale This can be attributed to the fact that they were
according to scientific qualification: The results in interested in developing the sports movement in Iraq by
table (4) show that the total score of the responses of activating the sports marketing practices within sports
the sample members on all fields of the scale according clubs. Deficiency in facilities, such as sports halls
to scientific qualification were close despite differences prevented these clubs from achieving positive financial
in scientific qualifications. This may be due to the laws returns, which are considered one of the most important
of elections in federations and clubs, which require the aspects of investment in sports institutions. Hassan
availability of scientific qualifications for members of Ahmed Al Shafei (2006), who claimed that one of the
the Union and the club regardless of the positions they main axes of investment in sports institutions is the
will occupy. The (High diploma) variable occupied the infrastructure and the need to have the necessary
facilities and tools and devices to promote sports
first position (81.71%) and at a very high level of
investment in sports institutions, confirmed this. This
education, followed by a (MS + PhD) variable with a
encourage sports investment in sports institutions.5
(80.17%) percentage and at a very high rate. The
(Bachelor) variable came in the last position with a Samir Abdelhamid (1999) emphasized that the
percentage of (79.11%) and a high level of appreciation. importance of using the concept of marketing in sports
institutions is the high contribution rates of businessmen
These results indicate that the strategies towards and the increase of financial support plays a significant
marketing sports of all members of the application role in achieving the objectives of the administrative
sample in are not influenced by their scientific body of the union and the club.6
qualifications.

Participants’ responses according to variable years of experience in administrative work

Table 5: Show the mean, standard deviations and percentage percentages of the scale fields according
to variable years of experience in administrative work

(1-5) years (6-10) years (11-15) years 16 years and above

Mean

Mean
SD

SD
78.50 Percentage

86.51 Percentage

79.00 Percentage

80.02 Percentage

Variables

Laws and
39.25

2.314

43.26

4.325

39.5

1.03
4.017

40.01

Regulations (Legal
Dimension)
Administrative
76.81

3.540

33.22
34.57

2.354

36.35

80.78

4.108

36.01

2.34

80.00
73.81

dimension
The economic

32.46

5.204

83.37
81.14

33.504

4.210

32.57

81.42

3.147
3.580

32.65

81.62
dimension of sports
marketing
The technical

36.29

3.356

38.20

84.89
80.64

3.014

37.89

84.2

2.01
4.001

33.36

74.12
dimension of sports
marketing
Technical 29.33

3.585

25.31
83.78

1.205

72.305

28.61

81.734

2.35
2.321

27.59

78.82
(technological)
dimension of sports
marketing
The Social
33.24

4.236

37.01

82.22
73.85

5.002

36.01

80.01

3.08
4.199

38.25

85.00
dimension of sports
marketing
The media
38.78

2.145

43.08

86.15
77.56

3.899

42.31

84.62

4.01
2.350

41.01

82.01
dimension of sports
marketing
256.7

82.80
243.91

23.194

78.68

25.195

250.1

24.576

80.67

248.87

17.96

80.28
Total

Level High Very high Very high Very high

Participants’ responses on all fields of the scale the three advanced centers are able to develop solutions,
according to variable years of experience in proposals and future perspectives on sports marketing
administrative work: The results in table (5) show as a result of their success and failure experience
the total score of the responses of the sample members gained through participation in local and international
on all the fields of the scale according to the variance sports competitions, and watching the sports marketing
of the years of experience in the administrative work. practices in those countries, especially the developed
The (1-5 years) variable showed 78.68%, the (6-10 countries in this field. This means that all employees
years) variable had 80.87%, and the (16 years and over) of sports clubs of different years of experience in the
variable had a percentage of 80.28%. After comparing administrative work emphasize the need to exploit
these percentages against the percentages adopted by the sports marketing by their various institutions to promote
researchers in order to interpret the results Responses the sports movement in Iraq and keep pace with the
of the sample to the scale As in Table (2) above, it was development in developed countries. This is consistent
found that a variable (6-10) years obtained first place at with one of the most important findings of Jamal
a very high level of estimation, followed by a second Mustafa Zuhairi’s (2010) study that “The marketing
variable ( 11-15 years) at a very high level, followed by process must be carried out in accordance with plans
the third rank variable (16 years and over) at a very high developed in advance by persons with high levels of
level, while ranked fourth and last variable (1-5) years experience to suit the developments and developments
at a high level. and the global situation in the field of sports marketing.7
These results indicate that the experience in Conclusions
administrative work was not significantly affected
1. The scale of sports marketing has been accepted
by sports marketing practices for the employees of
and reflected sports marketing in terms of sports
the Premier League football clubs in Iraq. However,
marketing practices from the viewpoint of the
the orientations of the experts who occupied the three
employees of the Premier League football clubs
highest positions were fairly close to each other and
in Iraq.
relatively less difference from the results of the fourth
and final variables (1-5) years. The researchers attribute 2. All employees of the Iraqi football Premier
these results to the fact that the experienced centers League clubs have a positive attitude towards
of
sports marketing, but the grants allocated by 3. Schaaf P. Sports marketing: it’s not just a
the Ministry of Youth and Sports and the Iraqi game
National Olympic Committee do not cover their anymore. Prometheus Books; 1995.
needs and affect the implementation of planned
4. Burnett J, Menon A, Smart DT. Sports marketing:
activities.
A new ball game with new rules. J Advert
3. The ‘Years of experience in administrative work’ Res.
variable (1-5 years, 6-10 years, 11-15 years, 16 1993;33(5):21–36.
years and over) had the highest high results for all 5. Kahle LR, Riley C. Sports marketing and the
fields of the scale. psychology of marketing communication.
4. The ‘scientific qualification’ variable (diploma and Psychology Press; 2004.
less, bachelor’s, master’s degree, and doctorate) 6. Tomlinson M, Buttle F, Moores B. The fan as
has achieved very high results for all fields of the customer: Customer service in sports marketing.
scale and less than variable years of experience in J Hosp Leis Mark. 1995;3(1):19–36.
administrative work.
7. Davis JA. The Olympic Games effect: How sports
5. The ‘functional’ variable (head, vice president, marketing builds strong brands. John Wiley &
secretary, member) has good results for all Sons; 2012.
fields of the scale and less than the variable of
scientific qualification and years of experience in 8. Shank MD, Lyberger MR. Sports marketing: A
administrative work. strategic perspective. Routledge; 2014.
9. Alsayigh HA, Athab NA, Firas M. Journal
Ethical Clearance: Taken from University of Anbar
of Global Pharma Technology The Study of
Source of Funding: Self Electrical Activity of the Triceps Brachia Muscle
according to the Chemical Changes of Water Loss
Conflict of Interest: None during Spike in Volleyball. 2017;57–62.
10. Al-mashhadi RAA. The Impact of the Plan and
References
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1. Shilbury D, Quick S, Westerbeek H. Strategic Cognitive Processes and Reducing Psychological
sport marketing. Allen & Unwin; 2003. Pollution Among Students of the Faculty
2. Bee CC, Kahie LR. Relationship marketing in of Physical Education and Sports Sciences.
sports: A functional approach. Sport Mark Q. 2018;928–35.
2006;15(2). 11. Alsayigh HA, Athab NA. The Study of Rectus
Femoris Activity after Knee Joint Rehabilitation.
2016;9(9):360–5.
DOI Number: 10.5958/0976-5506.2019.01663.2

Knowledge, Attitudes, and Behavior of Pregnant Women

in Preventing of Pregnacy Complication and Childbirth:
Application Study of Yudhia Model

Yudhia Fratidhina1, Nina Herlina2, Desri Suryani3, Yandrizal4

1
Departement of Midwife Politeknik Kesehatan Kementerian Kesehatan Jakarta III; 2Department of
Midwife Gunadarma University; 3Politeknik Kesehatan Kementerian Kesehatan Bengkulu;
4
School of Health Sciences Tri Mandiri Sakti Bengkulu

ABSTRACT
The high of maternal mortality rate (AKI) largely caused by a lack of knowledge and bad behavior of
pregnant women on high risk pregnancy treatment.This condition had impact the high maternal mortality
while childbirth.
The purpose of this study was to apply model participatory asset community development research in
action for pregnant women through mentoring on prevention of pregnancy complication and childbirth. The
study was done by using approach quasi experiment approach with the pre-post test design was 83
respondents. The application of this model at community done by YUDHA model.
The result showed that knowledge score before applying model was 41.20 after applying 70,55, the attitude
score before applying was 20.62 after applying model was 40.56, while the behavior score before applying
model was 30.50 and after applying was 70.48. YUDHIA model statistically could improve knowledge (p=
0.000), attitude (p=0.000 ) and behavior of pregnant women (p=0.000 ) compared before getting
mentoring.
The research conclusions that YUDHIA model could increase knowledge, attitudes and behavior of
pregnant
women on prevention of pregnancy complication and childbirth.
Keyword: pregnant women, pregnancy,
chlidbirth
Introduction hypertension and pre-eclampsia, anemia, placenta
previa, and diabetes2. While childbirth complication is
Maternal Mortality Rate (MMR) is one of the
difficult childbirth (dystocia) that causes a disease.
important indicators of the level of public health and
Childbirth complications include premature rupture of
able to be used in the monitoring of pregnancy-related
membranes, premature childbirth, abnormal fetal
deaths. This indicator is affected by general health
position.
status, education, and services during pregnancy and
childbirth1. The direct causes of maternal mortality Based on the Indonesian Demographic and Health
for more than Survey (IDHS) in 2012, MMR in Indonesia was high,
90% were a result of obstetric complications, mainly at 359 of 100,000 live childbirths. This figure increased
of childbirth complications. Pregnancy complications compared to MMR in 2007 which was at 228 (MOH
were obstetric emergencies that cause the death of the RI, 2010). Meanwhile, the 5th global target of the
mother and fetus. Pregnancy complications included MDGs (Millennium Development Goals) is reducing
MMR to 102 in 2015. Based on reports from the
Provincial Health Office of Banten, the highest MMR
Corresponding Author: was in Pandeglang. Complications of pregnancy and
Yudhia Fratidhina childbirth in Pandeglang district caused 34 cases of
Departement of Midwife Politeknik Kesehatan maternal mortality in 2013, 14 cases for bleeding, 8 for
Kementerian Kesehatan Jakarta III hypertension during pregnancy, 4 for infection, and 9 for
Email: [email protected] prolonged childbirths and other cases3.
741 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 741

One strategic move is improving the knowledge, Method

awareness, and motivation toward improved behavior
for the prevention of complications of pregnancy This study was a quasi experimental research with
and childbirth. It is able to be conducted through the pre- post test design. Place and time of study in District
empowerment and participation of family or community. Cimanuk in July-November 2016 (5 months). The
Empowerment goal is to increase the capacity and population was all pregnant women of trimester II and
capability of society to be able to recognize the III in Cimanuk sub-district, Pandeglang Regency, Banten
encountered problems, explore and exploit the available Province. The population of pregnant women was 800
resources, as well as show their existence clearly4. One person. The sample was taken using simple random
of the efforts to improve maternal health status and sampling method in pregnant mother of trimester II and
reduce maternal mortality rate (AKI) in Pandeglang III around the work area of Puskesmas (Public Health)
district is through improving knowledge, attitude, and in Cimanuk Sub-district, Pandeglang Regency, Banten
behavior of pregnant women in prevention of pregnancy Province, fulfilling inclusion and exclusion criteria,
and delivery complication, through application of 83 respondents. Questionnaires are used as a means of
Participatory Asset Model of Community Development collecting data. Before the quesioner is used the
Research In Action (YUDHIA) model which involves reliability test and the validity of the questionnaire are
the community in solving the problem. used. Data obtained in the form of knowledge, attitude
and behavior of pregnant women. Statistical analysis
YUDHIA models are expected to address issues using chi square.
related to the incidence of complications of pregnancy
and childbirth in the community in the prevention of Result and Discussion
pregnancy and childbirth complication. This study was
conducted in order to identify the aspects of Model Knowledge of pregnant women: Scores of
Participatory Asset Community Development Research respondents’s knowledge variable about the prevention
in Action (YUDHIA). behavior of pregnancy and childbirth complications
were presented in Table 1.

Table 1: Knowledge of Pregnant Women Before and After

Assisting YUDHIA Model
Variable N Mean Median SD Min-Max P
Pre 83 41.20 50 7.22 30-60
0.001
Post 83 70.55 60 6.30 54-80
Value of difference: 29.35
Source : Primary data, 2016
Knowledge analysis of pregnant women who knowledge of pregnancy and childbirth complication.
followed the assistance of YUDHIA Model resulted These results were in line with studies conducted in the
the average knowledge of pregnant women at first UK, that the midwives knowledge increased
measurement 41.20 with deviation standard 7.22, significantly after receiving obstetric training5.
minimum value 30 and maximum 60. While at second
measurement gived the average knowledge of pregnant In the pretest, the average score of respondents
women was 70.55 with a standard deviation was 6.30, a knowledge was only 41.20 (SD 7.22). It got into
minimum value was 54 and a maximum was 80. There the category of low knowledge, meaning less than
50% of knowledge about pregnancy and childbirth
was an increase of respondents’s knowledge score
complications which was known by the respondents.
before and after assistancing YUDHIA model was
Knowledge of bleeding was the most familiar to the
29.35. Statistical analysis indicated that YUDHIA
respondents. Studies which conducted in Uganda
assistance had a significant effect (p=0.001) on the
showed results that were not much different. Only one
change of pregnant women’s knowledge in the job area third of respondents knew at least three danger signs
of Pandeglang Regency. This study showed that the in the phases of pregnancy, childbirth, and postpartum.
implementation of the YUDHIA model significantly Among them most respondents said that bleeding during
changed the level of
pregnancy and swelling of the hands and face were signs Efforts to increase this knowledge was able be
of danger during pregnancy6. conducted with health promotion, both orally, in writing
and audio. One of the latest approaches in improving
Knowing the signs and symptoms of pregnancy
and delivery complications will make responders more knowledge and outcome of birth is Centering Parenting.
anticipated and prevented for mitigating the impact of Centering Parenting was a model that involving groups
pregnancy and childbirth complications by reducing the of 6-7 mother-babies together to get treatment for the
first two and late three if the health facility was ready first year. Through nine sessions, medical officers
to treath the complications6. The socialization about provided care and also provided information on health,
obstetric danger was key to finding health services infant development and baby-mother safety issues.
for obstetric emergencies and in find prevention or The program integrated three major components of
promotion efforts during pregnancy and childbirth. care, namely health, education, and support in-group
So the lack of awareness of dangerous signs will be assessment8.
related to the lack of preparation to conduct childbirth
normally as well as preparedness to face complications7. Attitude of Pregnant Woman: Changes in attitude of
Assuming that all pregnancies were at risk, the mother respondents before and after assisting YUDHIA model
should be aware of the signs of dangerous complications were shown as follows.
of pregnancy, childbirth, and postpartum.

Table 2: Attitude of Pregnant Women before and After Assisting YUDHIA model
Variable N Mean Median SD Min-Max
Pre 83 20.62 20 5,85 11 – 33
Post 83 40.56 40 6,23 34 – 55
Value of difference 19.94
Source : Primary data, 2016
The average attitudes of pregnant women in the had a positive attitude associated with mild bleeding,
first measurement was 40.56 with a standard deviation dizziness, and vomiting- gag. The rest assumed that
of 5.85, the minimum value was 11 and maximum was these signs were normal (negative attitudes), as
33. While in the second measurement obtained the delivered by the family and the environment around
average attitude of pregnant women was 40.56 with a pregnant women. With a positive attitude toward
standard deviation was 6.23, the value minimum was 34 pregnancy alert will trigger positive behavior in
and maximum was 55. There was an increase in attitude pregnancy examination and prevention of
scores of respondents before and after assisting complications9.
YUDHIA Model, the point was 19.94. The statistical
analysis showed that YUDHIA assistance had a One that influences respondents’s attitudes
significant effect (p = 0,001) on the change of attitude of toward pregnancy and childbirth complications was
pregnant woman in work area of Pandeglang Regency. maternal education, husband education, and education
from health workers10. All three factors were able to
This study showed that assisting YUDHIA Model increase awareness about the danger signs of pregnancy
significantly improved pregnancy attitudinal score on more than twice. It suggested that more exposure to
pregnancy and childbirthcomplications. Changes in information about complications, will enhance attitudes
so it gave an effect on decision making during pregnancy
and childbirth11. While information/promotion about
attitudes was observed in this study were more prevalent
pregnancy complications and delivery informations
on items about pregnancy screening. Research in Jordan
to pregnant women which was provided by health
showed there were as many as 91% of respondents who
workers will greatly affect the attitude of the mother.
had a positive attitude to perform pregnancy checks Furthermore, these attitudes will affect the behavior
during the emergence of alarm signs of pregnancy [14]. of pregnancy examination. It will be very important in
Unfortunately this study did not observe respondents’s detecting pregnancy complications and providing advice
attitudes toward the danger of pregnancy. A study in to pregnant women and families on timely follow-up
Argentina showed that only 30% of pregnant examinations12.
women
Behaviour of Pregnant Women: An overview of scores changes in pregnant women’s behavioral associated with
the prevention of pregnancy and childbirth complications is shown in the following table.3

Table 3: Behaviour of Pregnant Women Before and After Assisting YUDHIA

Model
Variabel N Mean Median SD Min-Max
Pre 83 30.50 32 8.52 18-54
Post 83 70.48 70 8.32 55-80
Value of Difference 39.98
Source : Primary data, 2016
The analysis result of pregnant women’s behaviour The pretest-postest presentation was conducted
who followed YUDHIA Model assisting got the average to determine whether or not the influence of assisting
of pregnant women’s behavior on first measurement YUDHIA Model toward knowledge, attitudes, and
(before, assistance) 30.50 with standard deviation 8.52, behaviors prevention of pregnancy and delivery
minimum value 18 and maximum 54. While in second complications. So that assisting YUDHIA Model on
measurement got the average behavior of pregnant prevention of pregnancy and childbirth complications
mother (after assistance) was 70.48 with standard able to be used by pregnant women as a guideline to
deviation of 8.32, minimum score 55 and maximum 80. prevent pregnancy and childbirth complications. The
There was an increase in score of respondent behavior YUDHIA model was conducted by involving health
before and after assistance YUDHIA model of 39.98. workers (midwives), families, cadres, and the
The statistical analysis showed that YUDHIA mentoring community. All the elements that played a role need to
had significant effect (p=0,001) on the change of get assistance to better understand the concept and role
pregnant women’s behavior in Pandeglang Regency. in implementing this YUDHIA model. In
After YUDHIA Model was conducted, there was a addition,assistancewas also provided to equate common
significant change in the prevention behavior of goals, it is to form behaviour pregnancy and childbirth
pregnancy and childbirth complications. The results of complications that finally able to be prevent
this study were in line with study in Garut, West Java, complications of pregnancy and childbirth.
that after receiving P4K training, the behavior of
childbirth was led in health personnel. The involvement of cadres and communities in
this model was very appropriate. Based on the results
Assisting YUDHIA Model was conducted of systematic review, cadres proved able to deliver the
intensively for 3-6 months until the mother maternity. message of preventive intervention of maternal and
In this assistance process, pregnant women received child health problems in developing countries and poor
continuous education and strengthening from cadres countries. Because the cadres was able to deliver the
about the signs of pregnancy complications. In addition, message directly to the target audience ie mother, using
the promotion of childbirth in health personnel continues the cultural and habitual approaches that apply in the
to be done. It is able to increase the knowledge of the community13.
respondents about the complications and ultimately
changed their behavior, one of which is performing
Conclusion
birth in midwife. By access, the community in Cimanuk
Sub-district had the financial ability to deliver to health YUDHIA model was implemented through the
personnel. Although there were some who could not process of assisting pregnant women by cadres. This
afford, but it could be overcome by the existence of assisting wasconducted from the second or third
saving maternity. In addition, with the availability of trimester of pregnancy to the maternity. As a tool in
waiting homes, pregnant women who were in the village assisting pregnant women, the cadre was equipped with
furthest from the health center able to wait in the waiting YUDHIA Model module. Assisting YUDHIA model
house that had been provided. significantly improved knowledge, attitude, and
behavior to prevent pregnancy and childbirth
complications.
Some recommendations that able to be delivered BJOG: An International Journal of Obstetrics &
related to pregnancy and childbirth complications, Gynaecology. 2007;114(12):1534-1541.
for example in overcoming the limitations of human
6. Mbalinda SN, Nakimuli A, Kakaire O, Osinde
resources in the field of health and limited health
MO, Kakande N, Kaye DK. Does knowledge of
facilities in Assisting YUDHIA model with
danger signs of pregnancy predict birth
empowerment approach and full participation of local
preparedness? A critique of the evidence from
asset-based communities is an intervention strategy in
women admitted with pregnancy complications.
an effort to reduce maternal mortality. Assisting
Health Research Policy and Systems. 2014;12(1),
YUDHIA model able to be used in assisting village
1.
midwife duties in the early detection and prevention of
complications of pregnancy and childbirth 7. Graham W, Themmen E, Bassane B, Meda N,
Brouwere DV. Evaluating skilled care at delivery
Conflict of Interest: The authors declare that there is no in Burkina Faso: principles and practice. Tropical
conflict of interest. Medicine & International Health. 2008;13(s1):6-13
Source of Funding: We are very grateful for the 8. Bloomfield J, Rising SS, Centering Parenting: An
funding from health polytechnic of health ministry Innovative Dyad Model for Group Mother‐Infant
Jakarta III which was very supported us in doing this Care. Journal of Midwifery & Women’s
research. Health.
2013;58(6):683-689.
Ethical Clearance: Health Research Ethics Committee,
Faculty of Medicine Andalas University of Padang 9. Rosenstein MG, Romero M, Ramos S. Maternal
mortality in Argentina: a closer look at women
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DOI Number: 10.5958/0976-5506.2019.01664.4

Intra and Inter-Rater Reliability of Web Plot Digitizer

Software in Quantifying Head Posture Angles

Yughdtheswari Muniandy1,2, Devinder Kaur Ajit Singh1, Suresh Mani1,3, Baharudin Omar1
1
Physiotherapy Program, Centre for Rehabilitation and Special Needs, Faculty of Health Sciences,
Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia;
2
Physiotherapy Program, Faculty of Health & Life Sciences, INTI International University, Nilai, 71800.
Negeri Sembilan, West Malaysia; 3Program Department of Physiotherapy, Lovely Professional University,
Phagwara, Punjab

ABSTRACT
Background: It is important to quantify postural misalignment to provide effective treatment. Web-plot
digitizer software (WPDS) was developed for analysis of posture angles. However, the reliability of this
software in quantifying head posture angles is not known.
Study Design: Repeated-measure study.
Method: A total of 31 participants were recruited. Head posture angles were measured using
Photogrammetry method and analyzed using WPDS. Intra-rater evaluations were performed twice by a
rater with a period of three weeks’ interval. Three raters reanalyzed all the photographic data for inter-rater
reliability.
Results: High level of reliability was demonstrated for intra-rater analysis in participants with and without
neck pain with ICCs ranging from 0.92 to 0.99 (SEMs: 0.10 to 0.88; CV: 1.65 to 10.77). The inter-rater
reliability between three raters was also high (ICCs: 0.98 to 0.99).
Conclusions: Excellent intra and inter-rater reliability was demonstrated using WPDS. WPDS can be used
in clinical setting for head posture assessment.

Keywords: Reliability; head posture angles; Web plot digitizer

software.
Introduction Therefore, correction of abnormal posture is crucial.
Effective management includes postural assessments
Forward head posture (FHP) is one of the most
which can inform the intervention selection 3. Clinically,
common abnormal posture associated with neck pain 1,2.
FHP assessment is mostly performed by observation in
FHP can be characterized as an excessive anterior
which it is widely dependent on clinical experience and
translation of the head in a sagittal plane1. These
subjective interpretation of the examiner4,5. Moreover,
postural malalignments can lead to an imbalance
studies have shown that existing method of postural
between cervical and shoulder synergists, predisposing
assessment have poor accuracy and low reproducibility
musculoskeletal injuries2.
between observers6.

Objective measures to assess FHP includes 3D

Corresponding Author: motion analysis, electromagnetic, optical devices
Devinder Kaur Ajit Singh and surface topography are known to be more precise
Physiotherapy Program, and reliable8. However, these techniques are mostly
Centre for Rehabilitation and Special Needs, laboratory based, costly and time consuming4,7. There is
Faculty of Health Sciences, a need for a feasible and reliable tool to measure FHP.
Universiti Kebangsaan Malaysia,
Jalan Raja Muda Abdul Aziz, 50300 Digital photographs has been used to measure
Kuala Lumpur, Malaysia FHP4,7,9,10. This method has been reported to be relatively
Email: [email protected] cheap, easy and fast6,8,10. Photograph method has
also
746 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 746

been demonstrated to have good intra rater reliability Equipment: Photographs were taken from lateral view
in measuring neck postural angles with interclass using a computer web-camera (Logitech C310, HD,
correlation coefficients (ICCs) of 0.56 to 0.89 and 0.93 1280 X 720). The camera was supported on a tripod and
to 0.99 respectively11. placed at a distance of 1.5 meters away from the line
marking the position of a participant. Landmarks were
Accordingly, postural assessment software has
placed on the floor to ensure the same positioning9. The
been developed to determine postural angles7. There are
camera lens axis was placed perpendicular to the sagittal
several FHP assessment software’s which are
plane of the participant at the height that
available
corresponded 7
such as Alcimage, All Body Scan 3D, Biotonix, with seventh cervical14. The C markers was placed in
Corporis
Pro, Fisiometer Posturogram, Physical Fisio, and the center of the lens to reduce parallax error 14. The
Software of Posture Assessment12. One of the limitation captured images were imported to WPDS to calculate
of these software’s are it requires special technical skills the FHP. The FHP angle was calculated by constructing
to operate, operating instructions are not in English and the lines from one landmark to the other. The following
the software’s need to be purchased12. variables were analyzed for measuring FHP angle as in
the Figure 1:
In addition, the reliability of these software’s are not
reported12. Thus, there is a need to have a reliable FHP
software to measure postural malalignment.

A software that will be useful is probably Web-Plot

Digitizer Software (WPDS). WPDS is a window based,
open resource application distributed under the General
Public License Version 3 that has a scientific tutorial
which can work with a variety of plots and images 13.
Nevertheless, the reliability of the WPDS has not been
studied.

Therefore, the aim of our study is to assess

reliability of WPDS in measuring head postural angles
in adults with and without Non Specific Neck Pain
(NSNP).

Method

Participants: A repeated measure study design was Figure 1: Sagittal head tilt (A),Craniocervical angle
adopted. A total of 31 participants were recruited by (B), and Shoulder angle (C).
convenience sampling method. The inclusion criteria
for participants without neck pain were those who have Procedure
not experienced neck pain for the past six months. The
exclusion criteria include congenital diseases with All the participants were instructed to stand
musculoskeletal impairments and balance disorders. comfortably in an upright position and to look straight
ahead to a distant point at eye level before each
The inclusion criteria for participants with neck photograph was taken16. Two reference frames for
pain were those present with complain of neck pain feet placement were placed on the floor to limit the
for the past 3 months or more. Whereas, the exclusion variability associated with participants’ positions. Before
criteria for neck pain participant includes presence of taking the photographs, the anatomical landmarks of
any neurological symptoms, congenital diseases which the participants were palpated and marked by the same
could modify the musculoskeletal systems and balance experienced physiotherapist using colored adhesive
disorder. Prior to data collection, all participants were tape 15. With these landmarks, the FHP angle were
given explanation about the study purpose, and informed calculated15.
consent was obtained.
Three physiotherapist who were not regular users of The CV is described as the estimation error of
WPDS were invited for inter-rater reliability analysis. measurement when usually the repeated measures are
Prior to the analysis, the raters were orientated about performed. The measure is considered reliable if the
how to use the software. CV is lesser than 15%18. CV is calculated based on the
formula in which, CV = (SD/X) 100
Data Analysis
The Bland – Altman plot was calculated to evaluate
Data was analyzed using statistical software the agreement between two trials of measurement. The
package SPSS (Version 22.0). The primary rater trial measures should lie between the probabilities
analyzed all the photograph images twice with a period of
of three weeks’ interval. Intra-rater reliability was 95% for a good, reliable measure18.
examined using intraclass correlation coefficients
(ICC), standard error of measurements (SEMs) and Results
coefficient of variation (CV). For inter-rater evaluation
of WPDS, three raters analyzed the photograph images All participants completed the trials and the data was
by calculating the postural angles independently. normally distributed. The mean and standard deviations
of participants’ characteristics are as depicted in Table 1.
The results of ICC values were classified as poor The ICC, SEMs and CV of the postural angles of
for 0 to 0.40; moderate for 0.40 to 0.75; and excellent participants are shown in Table 2. The intra-rater
for 0.75 to 1.0017. The SEMs was used to investigate reliability were excellent with ICCs ranging from 0.92 to
different sources of variation in test scores18. The measure 0.99 (Table 2). The SEMs and CV were between 0.10
is considered reliable if the SEMs is less than 5%18. to 0.88 and 1.65 to 10.7 respectively. These results
suggest a high level of intra-rater reliability in the
postural angle measurements.
Table 1: Descriptive characteristics of participants
Participants Without neck pain (n = 15) Mean (SD) With neck pain (n = 16) Mean (SD)
Age 24.6 (6.36) 24.5 (13.4)
BMI 22.5 (8.50) 24.9 (8.12)

Table 2: Intra-rater reliability analysis of postural angles

Without neck pain With neck pain
Posture Angles
CV SEMs ICC(95% CI) CV SEMs ICC (95% CI)
SHA 10.12 0.36 0.97 (0.93 – 0.99) 10.77 0.76 0.92 (0.79 – 0.97)
CCA 2.42 0.20 0.98 (0.96 – 0.99) 1.65 0.10 0.99 (0.98 – 0.99)
SA 6.35 0.88 0.96 (0.90 – 0.98) 3.46 0.30 0.98 (0.96- 0.99)
SHA: Sagittal Head Tilt angle; CCA: Craniocervical angle; SA: Shoulder angle.
The Bland-Altman plot for measurement of first 2 in participants with neck pain for sagittal head
trial and second trial in participant without neck pain angle
for sagittal head angles shows the mean difference revealed the mean difference of 0.3 with CI of
of upper
-0.2 with a confidence interval (CI) of upper limit 4.3
and lower limit -4.0 respectively (Figure 2). Cervical
angles had a mean difference of 0.17 with CI of upper
limit 3.4 and lower limit -3.0 respectively and shoulder
angle revealed the mean difference of 1.4 with a CI of
upper limit 10.5 and lower limit -7.6 respectively. The
Bland-Altman plot for measurement of trial 1 and
trial
limit 6.0 and lower limit -5.4 respectively, cervical angle
with the mean difference of 0.3 with CI of upper
limit
2.0 and lower limit -1.5 respectively, and shoulder angle
with the mean of 0.9 with CI of upper limit 5.5 and
lower limit -3.5 respectively. Visual analysis of all the
plots showed that all the measurement differences were
in between the ± 2SD, indicating that the scores of both
the measures had acceptable agreements.

The inter-rater reliability between three raters

demonstrated high level of reliability (Table 3). The
ICCs for inter-rater ranged from 0.98 to 0.99
demonstrate
excellent reliability between raters. The SEMs ranged from 0.08 to 0.40 and CV ranged from 0.02 to 0.06 which
demonstrated high inter-rater reliability. Therefore, the results suggest that the WPDS is reliable in measuring
postural angle.

Table 3: Inter-rater reliability analysis of postural angles

Rater 1 Rater 2 Rater 3
Angle CV SEMs ICC ( 95% CI)
Mean (SD) Mean (SD) Mean (SD)
SHA 15.94 (8.13) 16.57 (7.98) 16.57 (7.98) 0.06 0.10 0.99 (0.98- 0.99)
Without
CCA 47.02 (7.49) 47.77 (7.65) 48.18 (7.70) 0.02 0.08 0.99 (0.98 - 0.99)
neck pain
SA 52.43 (13.06) 51.73 (13.01) 53.95 (15.00) 0.05 0.40 0.98 (0.96 - 0.99)
SHA 18.89 (5.46) 19.21 (5.28) 19.10 (5.69) 0.05 0.09 0.99 (0.97 - 0.99)
With
CCA 43.26 (6.54) 43.29 (6.57) 43.70 (6.53) 0.02 0.08 0.99 (0.98 - 0.99)
neck pain
SA 50.08 (10.56) 48.34 (9.77) 49.66 (11.06) 0.05 0.32 0.98 (0.96 - 0.94)

Without Neck Pain With Neck Pain

Figure 2: Bland-Altman plot of two different trials

Discussion Another factor that could affect the reliability of
the study is perspective error20. In the present study
In our present study we examined the intra and inter perspective error was controlled by minimizing the
rater reliability of WPDS in measuring head posture rotational angle of neck by keeping the optical axis
angles. The results demonstrated that the intra and inter perpendicular to the postural angle.
rater of WPDS in measuring head posture was excellent.
Positioning of the head and the use of instruction to
Inter-rater reliability of WPDS was found to be a participant is also known to affect the measurements7.
excellent. These results were further supported with the Alteration in neck positioning may cause incorrect
findings of Bland-Altman plots, indicating that the two visualization of the markings. Whereas, the use of
trials in both participants with and without neck pain instruction to a participant can highly influence the
had acceptable agreements. Inter-rater reliability results human movements and position. In regard to this, the
of posture assessment using another similar software, error related to positioning of head and instructions to
postural assessment software (PAS) showed that the participants was minimized in our study by ensuring
values of 44.8% and 34.5 % respectively between rater 2 standardized positioning of the participants by providing
and 3 were non acceptable whereas the other raters had a clear and detailed instructions.
showed an acceptable reliability values7. Results from previous studies have supported
the usage of software as an accurate method in the
Inter-rater agreement in using such techniques
could have been influenced by many factors, measurements postural angles for clinical use5,10,21. The
including
reliability of a measurement system used clinically or in
experience and training of the raters on the usage of
research must be established in order to ensure that the
software. It is noteworthy, that usage of WPDS does error involved in measurement is small enough to detect
not require an experience computer user as it’s easy to actual changes in what is being measured12. Our study
operate. Similarly, inter-rater reliability of fibre angles results showed excellent reliability as we used stringent
from ultrasound images were found to be excellent methods and was based on the guidelines for reporting
(ICCs: reliability and agreement studies (GRASS).
0.94 and 0.97)19. These results could have been
influenced The limitation of the present study is that for
by recall bias in identifying the points on the images. the inter-rater reliability of measuring head postural
angles using WPDS, we limited the analyzing to the
An excellent intra-rater reliability of WPDS was photographic images. However, from the results of the
also demonstrated in our present study. The results of intra-rater reliability we speculate that the reliability
SEM and CV were small and in the acceptable ranges will remain to be excellent. Another limitation is that the
suggesting good measurement precision. These results validity of measuring postural angles using WPDS was
are consistent when compared to a previous study not performed as it was beyond the scope of this study.
reporting sagittal photographic spinal posture Future studies should explore examining intra and inter
assessment which demonstrated excellent reliability 10. day intra-reliability of measuring using WPDS and its
concurrent validity.
One of the factors that could have influenced the
reliability of postural angles using WPDS is the Conclusion
accuracy of palpations. Marker placements can result in
errors leading to high variability in measurements10. Excellent reliability of WPDS in measurements
However, error from difference in palpations were of FHP was demonstrated in our study. Hence, we
controlled by getting only one experienced recommend the use of WPDS for prevention of FHP as a
physiotherapist to do so throughout the study. screening tool and management in clinical practice as it
is reliable, easy and simple to be used.
The anatomical landmarks were marked using
colored tape to reduce the variability of measures. The Acknowledgements
quality of the photographs were also assured by using
same trained person to capture the image for the analysis The authors like to thank Dr. Leonard Joseph for
by the raters. We deduced that the inter-rater variability his guidance in the early stages of the study and all the
in our study would have been mainly from the selection participants for their participations.
of the points in constructing the lines from one landmark
to the other for measuring the angles.
Conflict of Interest: No conflict of interest. 10. Perry M, Smith A, Straker L, Coleman J,
O’Sullivan P. Reliability of sagittal photographic
Source of Funding: No funding.
spinal posture assessment in adolescents. Advances
Ethical Clearance: The Ethics committee of University in Physiotherapy. 2008 Jan 1;10(2):66-75.
Kebangsaan Malaysia (UKM 1.5.3.5/244/JEP-2016- 11. Dunk NM, Chung YY, Compton DS, Callaghan
042). JP. The reliability of quantifying upright standing
postures as a baseline diagnostic clinical tool.
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measurement of thoracolumbar curvature in
Gauthier F, Labelle H. Reliability of a quantitative
clinical posture assessment tool among persons older adults using an electromagnetic tracking
with idiopathic scoliosis. Physiotherapy. 2012 device. Archives of Physical Medicine and
Mar 1;98(1):64-75. Rehabilitation. 2010 Jan
1;91(1):137-42.
DOI Number: 10.5958/0976-5506.2019.01665.6

Proton Pump Inhibitor to the Hepatic Cirrhosis Patients with

Hematemesis Melena: A Retrospective Study

Zakiyah1, Didik Hasmono1, Muhammad Noor Diansyah1, Christiawan Ardianto1

1
Department of Pharmacy, Faculty of Pharmacy, Universitas Airlangga, Jl.
Dharmawangsa No.4 - 6, Airlangga, Gubeng, Kota SBY, Jawa Timur
60286

ABSTRACT
Background: The Proton Pump Inhibitor (PPI) can be given as supportive therapy in hepatic cirrhosis
patients with hematemesis melena during treatment at the hospital. However, the use of proton pump
inhibitor therapy as a supportive therapy for hepatic cirrhosis patients with hematemesis melena has not
been widely used in hospitals.
Objective: This study aims to determine the pattern of use of proton pump inhibitor (PPI) in patients with
hepatic cirrhosis with hematemesis melena in the hospital.
Method: This study is a retrospective descriptive non-experimental. Sampling was obtained from
secondary data medical records of patients that diagnosed hepatic cirrhosis with hematemesis melena. The
variables observed were patients with hepatic cirrhosis with hematemesis melena such as age, gende r, type
of drug, dose, route of use, the frequency of administration, duration of drug administration, and clinical
symptoms.
Results: The most widely used PPI was omeprazole with intravenous route with a dose of
1x40mg and
2x40mg (61.54%), oral omeprazole route with a dose of 2x20mg (7.69%), intravenous route pantoprazole
with a dose of 1x40mg and 2x40mg (5.13%), and intravenous lansoprazole route with a dose of 1x30mg
and
2x30mg (48.72%).
Conclusion: The pattern of using proton pump inhibitor therapy in hepatic cirrhosis patients with
hematemesis melena is different in each patient.

Keywords: proton pump inhibitor, hepatic cirrhosis, hematemesis melena, treatment

pattern
Introduction Department of Pharmacy, Faculty of
Pharmacy, Universitas Airlangga
Cirrhosis is ranked twelfth as the cause of death in Jl. Dharmawangsa No.4 - 6, Airlangga,
adults worldwide with a prevalence of 1.8% 1. Gubeng, Kota SBY, Jawa Timur
According to a report by a government hospital in 60286
Indonesia, the mean prevalence of liver cirrhosis is 3.5% Email: [email protected]
of all patients treated in the Internal Medicine ward,
or a mean of
47.4% of all liver disease patients treated.
Comparison
of the prevalence of cirrhosis in male: female is
2.1: 1

Correspondence Author:
Didik Hasmono
and the average age is 44 years 2. Cirrhosis is a diffusion
process characterized by fibrosis and changes in normal
liver structure to abnormal nodules. Hepatic cirrhosis
can be caused by many conditions, including;
consumption of alcohol, hepatitis B and C viruses,
immunological disorders, hepatotoxic substances 3.
Hepatic cirrhosis can result in complications of
hematemesis melena caused by an aneurysm of the veins
that leads to upper gastrointestinal bleeding 4.

Proton Pump Inhibitor (PPI) is a supportive therapy

given to patients with hepatic cirrhosis with
hematemesis melena 5. PPI works to suppress stomach
acid by the mechanism of inhibiting proton pumps
which prioritize the resistance of H +/K + -ATPase to
the gastric mucosa
6
. Some research data shows that PPI-class drugs
are
better than H2-receptor antagonists in acid
suppression
7
. The advantage of using PPI is due to its
superiority
752 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 752

in maintaining gastric acidity. Research data show that January 2015. Data collection for this study was carried
stomach acid disrupts clotting formation, increases out retrospectively. Where research data is obtained
platelet disaggregation and fibrinolysis. Therefore, from medical records of patients treated with the
inhibition of gastric acid and increased gastric acid pH diagnosis of hepatic cirrhosis with hematemesis melena
will improve clotting stability and reduce the incidence from January
of bleeding 8,9Fleming TR. A multiple testing procedure 2014 to January 2017 which is then put together into
for clinical trials. ... (2010. Commonly used PPI class the collecting sheet. Data observed includes; patient
drugs are esomeprazole, lansoprazole, omeprazole, profile (medical record number, patient identity, hospital
rabeprazole, and pantoprazole 10. entry and date of discharge, complaints and final
diagnosis, disease history and treatment history, and
The use of PPI in the long term has the potential to
laboratory data and clinical data) and profile of therapy
cause hypergastrinemia by 50-100% and will increase
data (type of drug, dose, frequency of administration,
gastric acid secretion after long-term use of PPI. The
route of administration, and duration of therapy). Data
results of a systematic review of the evaluation of
analysis was based on data obtained from the Medical
acid hypersecretion showed that there was a rebound
Health Record (RMK) of hepatic cirrhosis patients with
after the use of PPI for 8 weeks 11. Other side effects
hematemesis melena. Data obtained from data collection
that occur in PPI use include diarrhea, abdominal pain,
sheets are put together into the main table and then
constipation, nausea, vomiting, and bloating 12. Based
processed statistically and analyzed descriptively in the
on the description above, the use of PPI in patients with
form of tables, diagrams, graphs or narratives.
hepatic cirrhosis with hematemesis melena still needs to
be studied further because it is possible for DRP (Drug
Related Problems). Results

PPI Treatment Profile: From the results of the study,

Materials and Method hepatic cirrhosis patients with hematemesis melena who
received therapy shown in Table 1.
This study uses a non-experimental or observational
with the descriptive retrospective design. Subjects
in this study were patients diagnosed with hepatic Table 1: PPI therapy profiles based on PPI Types
cirrhosis with hematemesis melena who received PPI PPI Drugs Amount Percentage (%)
therapy in the inpatient room of Airlangga University Omeprazole 24 61,54
Hospital Surabaya city for the period of January 2014 to
Lansoprazole 13 33,33
December 2016. Where the subject was determined by
Pantoprazole 2 5,13
the Time-Limited Sampling method by means of each
patient who fulfilled Research criteria were included Total 39 100,00
in the study during a certain period of January Profile of route of use, dose, and frequency of
2014 to PPI
therapy used can be seen in Table 2.
Table 2: Routes, dosages, and frequency of PPI therapy
PPI Drugs Route Frequency & Dose Amount Percentage (%)
i.v 2.dd.40 mg 23 58,97
Omeprazole i.v 1.dd.40 mg 1 2,56
p.o 2.dd.20 mg 3 7,69
i.v 2.dd.40 mg 1 2,56
Pantoprazole
i.v 1.dd.40 mg 1 2,56
i.v 2.dd.30 mg 13 33,33
Lansoprazole
i.v 1.dd.30 mg 6 15,38
Note: *) One patient can receive more than one medication for treatment
In the use of PPIs, each patient gets a different duration of treatment depending on the clinical effects caused by
each patient can be seen in Table 3.
Table 3: Duration of PPI usage
PPI Drugs Duration Amount Percentage (%)
Omeprazole < 4 weeks 27 69,23%
Lansoprazole < 4 weeks 19 48,72%
Pantoprazole < 4 weeks 2 5,13%

The profile of the substitution of type, dose, and route of PPI in hepatic cirrhosis patients with
hematemesis
melena can be seen in table 4.

Table 4: Profile of PPI type, dosage and route replacement

Substitution Profile Amount Persentase (%)
Drugs Substitution
Pantoprazole (2x40 mg)/iv Lansoprazole (1x30 mg)/iv 1 2,56
Omeprazole (2x40 mg)/iv Lansoprazole (2x30 mg)/iv 3 7,69
Lansoprazole (2x30 mg)/iv Omeprazole (2x40 mg)/iv 1 2,56
Doses Substitution
Omeprazole (2x40 mg)/iv Omeprazole (1x40 mg)/iv 1 2,56
Lansoprazole (2x30 mg)/iv Lansoprazole (1x30 mg)/iv 2 5,13
Route Substitution
Omeprazole (2x40 mg)/iv Omeprazole (2x20 mg)/po 3 7,69

The list of other drug therapies given to patients with hepatic cirrhosis with hematemesis melena can be seen in
table 5.

Table 5: Other drug therapies received by patients

No. Therapy Group Drugs type Amount Percentage (%)
1. Cefotaxime 23 58,97
Ceftriaxone 4 10,26
Antibiotic
Ciprofloxacin 3 7,69
Levofloxacin 1 2,56
2. Metoclopramide 2 5,13
Ondansentron 9 23,08
Antiemetic
Primperan 7 17,95
Domperidone 1 2,56
3. Antifibrinolytic Tranexamic Acid 22 56,41
4. Antireflux & Antiulcer Sucrafate 21 53,85
5. B-blocker Propanolol 3 7,69
6. Coagulation agent Vitamin K 23 58,97
7. Loop Diuretics Furosemide 4 10,26
8. Potassium-sparing Diuretics Spironolacton 7 17,95
9. Laxative Lactulose 23 58,97
10. Splanchnic vasoconstrictor Octreotide 2 5,13

Identification of Drug Related Problem (DRP): Potential interactions can be seen in Table 6.

Table 6: Potential drug interactions

PPI Drug Other Drug Drug Interactions Amount Percentage (%)
Furosemide can increases hypomagnesia
Omeprazole Furosemide 4 10,26
effect from omeprazole
Patients with hepatic cirrhosis with hematemesis or their carer or guardian. Local commissioners and/or
melena potential interactions between PPI therapy and providers have a responsibility to enable the guideline to
other drugs occur in the interaction of omeprazole with be applied when individual health professionals and
furosemide which can increase hypomagnesia. their patients or service users wish to use it. They should
do so in the context of local and national priorities for
Discussion funding and developing services, and in light of
their duties to have due regard to the need to eliminate
In the results of this study, the types of PPIs used unlawful discrimination, to advance equality of
were omeprazole, lansoprazole, and pantoprazole. opportunity and to reduce health inequalities. Nothing in
Omeprazole is the most therapy used by patients with this guideline should be interpreted in a way that would
hepatic cirrhosis with hematemesis melena in hospitals be inconsistent with compliance with those duties.
because omeprazole has a more cost-effective price Gastro-oesophageal reflux disease and dyspepsia in
because it is registered with the Social Security adults: investigation and management (CG184.
Organizing Agency (BPJS), so many patients use
omeprazole. There was no significant difference in The type of PPI given in less than 4 weeks, namely
effectiveness between omeprazole and lansoprazole at omeprazole, lansoprazole, and pantoprazole, provided
standard doses. When the frequency of administration that patients can get more than one type of PPI. The use
added to twice a day, omeprazole is better for inhibiting of long-term PPI with a potential of hypergastrinemia
gastric acid at night than lansoprazole 13omeprazole and increases gastric acid secretion by 50-100% after long-
lansoprazole provide effective acid suppression and term use of PPI 11. The results show that there were
equal healing and symptom relief in patients with patients receiving PPI substitution from pantoprazole
GERD. Despite this, controversy exists as to the 2x40 mg iv. daily to lansoprazole 1x30 mg iv. daily.
efficacy of available proton pump inhibitors in the Pantoprazole has a t½ that is longer than lansoprazole
control of gastric acidity. AIM: To assess the efficacy of (t ½ = 1 hour) which is 2 hours 17Helicobacter pylori
omeprazole 20 mg vs. lansoprazole infection, gastrooesophageal reflux disease, nonsteroidal
30 mg and omeprazole 40 mg vs. lansoprazole 30 mg anti-inflammatory drug (NSAID. Therefore, the
in intragastric pH control. METHODS: Study I: 12 substitution is appropriate because it reduces the time to
Helicobacter pylori-negative volunteers (mean age suppress stomach acid due to the development of clinical
33 years. Pantoprazole in standard doses has the symptoms. In addition, there was one patient who
same effectiveness as omeprazole in inhibiting proton received PPI substitution from omeprazole 2x40 mg iv.
pumps 14. Omeprazole is most frequently used by the daily and one of the patients that received lansoprazole
intravenous route because the oral route of omeprazole 2x30 mg iv. also get dose substitutions to
lansoprazole
has acid degradation in the digestive tract 15. In this
1x30 mg iv. daily, this dose substitution was also
study, omeprazole was administered at a dose of 2x40
appropriate due to the development of Clinical
mg daily and 1x40 mg daily intravenously and given a
symptom, so there is no need for high doses or
dose of 2x20 mg per oral. daily. Lansoprazole is given
intravenous use. For route substitution, namely
at a dose of 1x30 mg daily and 2x30 mg daily, for
omeprazole iv. to omeprazole
pantoprazole given at a dose of 1x40 mg daily and 2x40
2.dd.20 mg PO, daily. This replacement can be caused
mg daily. Standard dose was omeprazole 1x40 mg daily,
because the patient’s condition has begun to improve
lansoprazole 2x30 mg daily and pantoprazole 1x40
because oral administration is not always possible in
mg
critically ill patients or with decreased awareness .
daily omeprazole 2x40 mg daily 16arrived at after careful
18

consideration of the evidence available. When to the circumstances of the individual patient, in
exercising their judgement, professionals are expected to consultation with the patient and/
take this guideline fully into account, alongside the
individual needs, preferences and values of their patients
or service users. The application of the
recommendations in this guideline are not mandatory
and the guideline does not override the responsibility of
healthcare professionals to make decisions appropriate
PPI substitution of omeprazole 2.dd.40 mg iv. daily
to lansoprazole 2.dd.30 mg iv. daily, this substitution
caused by the ability of lansoprazole in binding to
protein by 98%, that leads to longer suppression
effect of gastric acid 19. The substitution is expected to
compensate for the clinical symptom with longer gastric
acid suppression effect from lansoprazole. After that,
the substitution of lansoprazole 2.dd.30 mg iv. daily to
omeprazole 2.dd.40 mg daily, this substitution is
based
on omeprazole ability as the fastest PPI group that reach study, it was possible to interact between omeprazole
peak serum concentration 20. and furosemide. Drug interactions occur with moderate
severity. Long-term PPI use can cause hypomagnesia,
Other therapies given for hepatic cirrhosis patients
and furosemide can cause an increased effect of
with hematemesis melena which are most widely given
hypomagnesia from omeprazole 20. In this study, plasma
in this study are antibiotics including cefotaxime,
magnesium levels were not tested to determine the
antifibrinolytics namely tranexamic acid, sucralfate,
incidence of hypomagnesia.
vitamin K, and laxatives including lactulose. There
is an ulcer in the upper gastrointestinal tract and also
caused damage to the Kupfer cells of the liver and if Conclusion
accompanied by ascites it could trigger SBP. Therefore The most frequently used of PPI Drugs in hepatic
hepatic cirrhosis patients with hematemesis melena are cirrhosis patients with hematemesis melena is
given antibiotics as infection prophylaxis. Cefotaxime omeprazole in intravenous route. Drug Related
is the most widely administered antibiotic because Problems (DRP) that occur in PPI treatment and other
cefotaxime is the third generation of a cefolosporin class drug therapies in patients with hepatic cirrhosis with
which has a very broad working spectrum, stronger hematemesis melena have found potential interactions
antibacterial activity and relatively lower side effects 21. between the PPI such as omeprazole with furosemide.
Administration of tranexamic acid which is an
antifibrinolytic group aims to reduce or stop active Acknowledgments
bleeding 22. Tranexamic acid can reduce upper
The author would like to express gratitude to all
gastrointestinal bleeding and stabilize the patient before
members of the Department of Fisheries and Marine,
endoscopic treatment 23we found that tranexamic acid
Faculty of Fisheries and Marine Universitas Airlangga,
may reduce mortality. The present review includes
Indonesia.
updated searches of randomised trials on tranexamic
acid versus placebo, cimetidine or lansoprazole. To Ethical Clearance: This research has gone through
assess the effects of tranexamic acid for upper ethical testing in the Ethics and Law Committee of
gastrointestinal bleeding. Electronic searches (The Universitas Airlangga Hospital No. 103/KEH in 2017.
Cochrane Library, MEDLINE, EMBASE, Science
Citation Index. In this study patients were also given Conflict of Interest: The authors declare that there is no
Vitamin K, this is intended to help the blood clotting conflict of interest
process. Lactulose is given to prevent constipation in
Source of Funding: This research was carried out by a
these patients and to prevent the chance of toxic
team and funded independently
substances to pass from the intestine to the liver which
in turn can cause hepatic encephalopathy 24. Patients
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DOI Number: 10.5958/0976-5506.2019.01666.8

Acceleration of Socket Healing by Using Placental Collagen

with BDNF: Radiological and Histological Studies

Athraa Y. Al-Hijazi1, Imad K. Abbas Al-Rifae1, Zaid M.Akram2, Luay Nafaa Kaka3
1
Al-Mustaqbal University College, Dentistry Department, Babel, Iraq; 2Al-Rafidain University College;
3
College of Dentistry, Uruk University

ABSTRACT
Background: Alveolar bone regeneration can be guided by the application of a collagen protein
coupled
with neuroinductive protein, following tooth extraction.
Aim of the study: The present study was designed to evaluate the radiologic, histologic and
histomorphometric aspects of socket healing in extraction site received placental collagen with brain-
derived neurotrophic factor(BDNF), compared with control site that healed spontaneously.
Materials and Method: Twelfth Sprague-Dawley male rats were subjected for a surgical tooth extraction
of upper central teeth of both sides. The right side be the control one as the socket healed spontaneously.
while left side be the experimental site, as tooth socket treated with 1μL of placental collagen with 1μL of
BDNF. The rats were scarified at 2 and 4 weeks post extraction. Socket healing was examined
radiographically and histologically.
Results: Experimental site illustrates trabecular bones formation between the peripheral and central regions
of the sockets at 2 weeks and increment of bone formation was observed, filled most of socket at 4 weeks
with reepithelization recognized at the surface. Radiographical view shows radiopaque that comprising 50%
to 74% of the overall area of the socket and was assigned a score of 3 with a high p value in comparisum to
control.
Conclusion: The present study, high lighted on osseo-inductive effect of the local application of placental
collagen with BDNF in socket healing.

Keywords: alveolar bone,bone regeneration,socket healing,BDNF,collagen protein,tooth

extraction
Introduction The use of the collagen matrix could be a clinical
option to preserve post-extraction ridges especially when
The alveolar socket walls undergo a physiological
an improvement in soft tissue quality is desired. [6] Many
changes and remodeling process with a variable
experiment were done to analyze processes involved in
molecular interaction events after tooth extraction.
the incorporation of Bio- Collagen in host tissue during
Different socket preservation techniques and materials
healing following tooth extraction.[7,8,9]
have been proposed to facilitate healing.[1,2]Most of
techniques consist to fill the alveolar socket with Brain-derived neurotrophic factor reported to be
different enhancing materials that act as stimulants or involved in differentiation and proliferation of non-
scaffolds for bone growth and initiate epithelization of neuronal cells, such as endothelial cells, osteoblasts that
the braked mucosa.[3,4,5] have been recognized to be also involved in regulating
tissue formation and healing in skeletal tissues. [10]Also,
this neurotrophin can enhance expression of osteogenic
Corresponding Author: factor, BMP-2, as well as the major angiogenic
Athraa Y. Al- factor,vascular endothelial growth factor VEGF that
Hijazi promote bone formation and enhance vascularization,
Al-Mustaqbal University College, and healing of the injury site. [11,12]Therefore, the present
Dentistry Department, Babel, Iraq study is the first report on the application of
Email: [email protected] placental
759 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 759

collagen coupled with brain-derived neurotrophic factor the overall area of the socket was assigned a score
as enhancing material for bone regeneration and socket of
healing. 2; (d) a radiopaque area comprising 50% to 74% of the
overall area of the socket was assigned a score of 3; and
Materials and Method (e) a radiopaque area comprising 75% or more of the
overall area of the socket was assigned a score of 4.
Animals: Twelfth Sprague-Dawley male rats aged (10– Each section was scored by 2 independent examiners.[13]
12-week) and weight (250–300 g) were kept in the
animal department of (National Center of Drug Control Histological Examination and Assessment: The
and Research/Iraq) at a constant humidity and premaxilla were resected cutting till the end of dental
temperature of 23°C according to the National canal, fixed in 10% buffered formalin, decalcified in
Council’s guide for the care of laboratory animals.The 10% formic acid, dehydrated and embedding in paraffin
rats were subjected for a surgical tooth extraction of wax then serial cut 5μm cross section and stained with
upper central incisors ( right side was considered as Hematoxylin and Eosin.
control site, that tooth socket healed
All these sections were examined under light
spontaneously,while left side(experimental site) received
microscope to evaluate the healing of extraction
1μL of placental collagen with 1μL of BDNF
wounds.
Materials
In addition, histomorphometry was used to assess
z Placental Collagen protein (N0. C-7521,SIGMA P). the amount of new bone formation, by estimation of
A lyophilised powder that can be reconstituted trabecular separation (Tb.Sp, in microns) in different
in portions of socket healing(coronal,middle and apical),
sterile water at 1 mg/ml. each section was evaluated by 2 independent examiners
at 10x.
z Lyophilised BDNF protein 10µg (ab9794)/
Abcam,the protein was reconstitute in water to a
concentration of 0.01mg/ml. Results

Histologic examinations revealed an absence of

Method inflammatory cells in all studied sites, whereas bone
formation and epithelization varied in the experimental
Surgical Procedure: After anesthetizing the animal by
compared to control and according to different periods.
general anesthesia the upper left and right central
incisors extracted by simple extraction without trauma. At 2 week post extraction period, histological
The left socket treated with a combination of 1μL feature for control site shows bone trabeculae coalesce
placental collagen and 1μL of BDNF as experimental peripherally with bone socket. Radiographical view
site, while the right one left without treatment (control ).
shows radiolucent in the socket with some radiopacity
The two sockets were sutured with black silk suture.Ratspresent along the wall of the extraction sockets. While
were sacrificed at 2 and 4wk post-extraction for the experimental site illustrates trabecular bones formation
analysis of the extraction sites. (n = 6 in each group at
between the peripheral and central regions of the
different sacrificed time point)
sockets. Radiographical view shows mixed of
Radiographic Examination and Grading: Clinical radiolucent and radiopaque filled the middle portion
radiographic examination was used to evaluate the with substantial amount of detectable calcification that
degree of bone mineralization (DBM) in the extraction present in the extraction sockets, lamina dura still intact
sockets during healing.The semiqualitative grading and visible. Figures(1,2,3)
system used for radiographically examining DBM was
At 4 week healing period, histologic description for
based on the following parameters at 10× magnification:
control site shows trabecular bone at central and
(a) sections with no evidence of radiopacity were
peripheral portions of the socket that confirmed by
assigned a score of zero; (b) a radiopaque area
radiographic film that illustrates mixed view of
comprising less than 25% of the overall area of the
radioopacity and radiolucent with detectable
socket was assigned a score of one; (c) a radiopaque
area comprising 25% to 49% of
760 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 760
calcification. Epithelization was not recognized for control.

For experimental site, histologically, shows new

bone filled most of socket with fibrous tissue over it.
Reepithelization appears at the surface. Radiographical
view shows radiopacity filled most of apical, middle
and coronal portions of the socket with lamina dura
disappeared partially. Figures(4,5,6)

Figure 4: Alveolar socket for control at 4 week

duration shows trabecular bone(BT) at central and
peripheral of the socket.H&Ex10

Figure 1: Alveolar socket for control at 2 week

duration shows bone trabeculae coalesce
peripherally with bone socket.H&Ex10

Figure 5: Alveolar socket for exp. at 4 week duration

shows new bone(B) filled most of socket with fibrous
tissue(FCT) over it.H&Ex4

Figure 2: Alveolar socket for experimental at 2 week

duration shows trabecular bones formed between
the peripheral and central regions of the sockets.
H&E x10

Figure 6: Conventional radiographic view for both

sides control and experimental of socket 4weeks
duration shows radioopacity and radiolucent . In
experimental side shows more radiopacity and
include most of apical, middle and coronal portion of
Figure 3: Conventional radiographic view after socket. Note: partial disappear of lamina dura
2 week illustrates Control (right )side with some internally in experimental side
radiographically detectable calcification was present
along the wall of the extraction sockets,while exp. Statistic Analysis
(left) side shows a substantial amount of
radiographically detectable calcification was present Results show less record for trabecular separation
in the extraction sockets measurement in experimental site in comparisum to
Note: lamina dura still intact and visible. control.And in the apical portion for both studied
sites
in comparisum to other portions.Moreover, trabecular socket and assigned score, 2 that recorded in 4th week of
separation measurement decreased as the period proceed control and in 2nd week for experimental site. Whereas,
in both control and experimental sites with a high radiopaque that comprising 50% to 74% of the overall
significant P≤0.01Value.Tables(1,2) area of the socket, assigned a score 3, was recognized in
experimental site at 4th week post operatively with a high
Radiographic Grading Score: Radiopaque area
p value in comparisum to control. Table(3)
comprising 25% to 49% of the overall area of the

Table 1: Trabecular separation in different portions of socket healing

Experimental Control
Portions 2wks 4wks 2wks 4wks
Mean S.E Mean S.E Mean S.E Mean S.E
Coronal
15.25 2.5 11.5 .29 26.4 2.7 16.75 .62
Middle 17 0.41 9.75 .25 22.5 2.1 14.25 .63
Apical 15 .72 8.25 .62 18.5 1.3 13 .92

Table 2: ANOVA for trabeculae separation

Source of variance df MS F P
Groups (Exp, Control) 1 442.43 216.879 P≤0.01*
Portions (Coronal,Middle,apical) 2 312.53 76.601 P≤0.01
Weeks (2,4) 2 286.79 140.581 P≤0.01
*P≤0.01 : high significant
Table 3: Radiographic grading score regions of the sockets and bone formation was observed,
filled most of socket at 4 weeks with reepithelization of
Radiographic
Periods F P braked mucosa,these results may related to the use of
grading score
placental collagen which is a protein that’s an important
Control 0.8
2 Weeks 26.601 P≤0.01* building block for bone and made the scaffold of the
Exp. 1.3 bone. Moreover,collagen also, promote a regenerative
Control 2.4 response including its effectiveness for acceleration of
4 weeks 11.581 P≤0.01
Exp. 3.6 osteoblasts growth, [16] its potential role in preserving
osteogenic potential of mesenchymal stem cells[17], and
*P≤0.01 : high significant its ability to enhance angiogenesis.[18]

Mesenchymal stem cells MSCs differentiate directly

Discussion
into osteoblasts, which secrete an osteoid matrix to form
Socket healing is a complex physiological process bone, [19]as illustrates in 2 week duration of socket
involving a coordinated interaction of hematopoietic healing. Furthermore, application of neurotrophin
cells, immune cells within the clot plug, in conjunction (BDNF) effects on vascular endothelial growth factor
with development of new vascular bud and bone VEGF that promote bone formation and enhance
cell precursors. Multiple factors regulate healing at vascularization, therefore,the present study records score
molecular events, which affects different stages in 3 for radiographic grading of experimental site which
the osteoblast, endothelial,epithelial lineages during indicated for the enhancement of newly bone formation
multiple processes such as migration, proliferation, and accelerate of socket healing. [20,21] Thus, bone
chemotaxis, differentiation and protein synthesis.[14,15] formation and reepithelization process that detected in
In present findings the experimental site illustrates experimental site depend, in part, on the presence of
trabecular bones formation in the peripheral and central placental collagen and in part to the role of the combined
BDNF.
Conclusion Porcine-Derived Bone Graft: a Comparative
Histological and Histomorphometric Analysis.J
Our preliminary results suggest that the association
Oral Maxillofac Res. 2017 Dec 31;8(4):e4.
placental collagen plus BDNF may be a valuable method
doi:
for socket healing.
10.5037/jomr
6. Cioban C, Zăgănescu R, Roman A, Muste A,
Acknowledgment
Beteg F, Câmpian RS, Boşca B. Early healing
This work was supported by Prof. Dr. Hasan Majdi after ridge preservation with a new collagen
Dean of Al-Mustaqbal University College, Babel, Iraq matrix in dog extraction sockets: preliminary
observations.Rom J Morphol Embryol.
Ethical Clearance: All work of this study had done 2013;54(1):125-30.
according to the National Council’s guide for the care of
7. Araújo MG, Lindhe J.Ridge preservation with
laboratory animals.
the use of Bio-Oss collagen: A 6-month study
Source of Funding: By ours in the dog.Clin Oral Implants Res. 2009 May;
20(5):433-40.
Conflict of Interest: Nil
8. Sun Y, Wang CY, Wang ZY, Cui Y, Qiu
ZY, Song TX, Cui FZ. Test in canine extraction
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3. Jambhekar S, Kernen F, Bidra AS.Clinical and J, Xian CJNeurotrophin-3 Induces BMP-2 and
histologic outcomes of socket grafting after VEGF Activities and Promotes the Bony Repair
flapless tooth extraction: a systematic review of of Injured Growth Plate Cartilage and Bone in
randomized controlled clinical trials.J Prosthet Rats.J Bone Miner Res.2016 Jun;31(6):1258-74.
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Shang-Jye Tsai et al. A Novel Chitosan-γPGA
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DOI Number: 10.5958/0976-5506.2019.01667.X

Study the Effect of Lycium barbarum Polysaccharide on Bone

and
Thyroid Gland in Hyperlipidemic Healthy Male Albino
Rats

Heba A. Abd-Alsalam Alsalame

College of Education for Pure Science, University of Kerbala, Iraq

ABSTRACT
The aim of the study was to determine the protective role of Lycium barbarum Polysaccharide against
the development of osteoporosis and hypothyroidism induced by high cholesterol diet in male albino
rats, 45 male albino rats were grouped into three sets. The first group (G1) was fed with normal diet and
considered as a control group. The second group (G2) was fed 2% cholesterol-enriched diet for three
months to induction of hypercholesterolemia, while The third group (G3) was fed 2% cholesterol-
enriched diet
+100mg/kg of Lycium barbarum Polysaccharide (LBP). Blood samples were withdrawn after starvation of
the animals at night, after the end of three months, 5 ml of blood was withdrawn from the heart to measure
the following parameters: concentration of total cholesterol (TC), High density lipoprotein (HDL), Low
density lipoprotein (LDL), Very low density lipoprotein (VLDL), Triglyceride (TAG), Alkaline
Phosphatase (ALP), phosphorus (p+), Calcium (Ca+), Parathyroid Hormone (PTH), Thyronine (T3),
Thyroxin (T4) and Thyroid stimulating hormone Hormons(TSH). Rats in G2 had significantly greater
levels of TC, TAG, LDL, and VLDL compared to G1, while the picture was an opposite direction in the
levels of HDL. G2 rats had significantly greater levels of PTH, calcium and phosphorus, while ALP levels
were significantly reduced compared to that observed in G1 rats. Levels of thyroid hormones (T3, and T4)
were significantly decreased, while the TSH levels were significantly increased in the G2 rats compared to
that of G1 rats. Rats in group
3 did not reveal any significant changes in all measured biomarkers comparing to that values measured in
G1. It is concluded from the present study that hyperlipidemia increases osteoporosis risk and causes
thyroid dysfunctions and confirms the protective role of the Lycium barbarum Polysaccharide against
osteoporosis risk and maintain thyroid dysfunctions in male albino rats.

Keywords: Lycium barbarum, Polysaccharide, bone, thyroid gland, male, albino

rats.
Introduction Hyperlipidemia is now recognized that can be
seriously detrimental as a main risk factor for fatty
Hyperlipidemia, a wide term, also called liver, atherosclerosis and stroke1. Osteoporosis and
hyperlipoproteinemia or lipemia is the condition in cardiovascular disease are the two main diseases related
which one of the serum biomarkers of lipid profile is to increase the risks of illness and death in the senility
elevated. These biomarkers involve triglycerides (TAG), population. Hyperlipidemia, result from many factors
total cholesterol (TC), and low-density lipoprotein like increased dietary consumption or genetic mutations,
cholesterol (LDL)1. Hyperlipidemia is formed due to the such as in deficiency of LDL receptor, has pernicious
potential lack of lipid metabolism or transport of plasma effects on the blood vessels, such as progress the
–derived lipids or a disturbance in both generation calcification of blood vessels. In hyperlipidemia, much
and of LDL particles pass to subendothelial space cross the
degeneration of lipoproteins2. endothelial barrier, where they are convert by reactive
oxygen species that created by macrophages and
adjacent
smooth muscle cells3. In human osteoporotic bone a same
Corresponding Author: Heba A. Abd-Alsalam Alsalame College of Education
for Pure Science, University of Kerbala, Iraq
Email: [email protected] process happen, the particles of oxidized lipoprotein
accumulate in the perivascular subendothelial spaces 4.
Many cells in the bone like Osteoblasts having the
ability to modify of lipoproteins particles3, and produce
of lipid oxidation in the bone marrow of hyperlipidemic
mice3,4.
765 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 765

Lycium barbarum L. is one of the Chinese materia The concentration of cholesterol, was measured
medica (CMM) that plays many biological roles. These according to method8, the determination of the
biological roles may have come from its components concentration of HDL was done by enzymatic method9.
that include polysaccharides, zeaxanthin, and While LDL was measured according to the Friedewald
cerebroside, betaine, p-coumaric acid, and β-sitosterol. equation. VLDL concentration can be calculated by
Specifically, polysaccharides derived from Lycium
dividing the value of TAG by (5)10, The concentration
barbarum (LBP) have been suggested to have
of triglycerides by enzymatic method was estimated
influences on different physiological processes such as
according to the method11. ALP, p+, Ca+, PTH, T3, T4
glucose regulation, antioxidant system, and immunity,
and TSH concentrations were measured by Kits using
antihyperlipidemia, antihypertension, and anticancer 5,6..
Recently, many studies indicated that LBP has Enzyme-Linked Immunosorbent Assay (ELISA) using
antioxidant property which may mitigate the potential the Axiom Minireader ELISA Reader.
DNA damage. Therefore, the current study was
Statistical Analysis: Results were statistically analyzed
conducted to test the efficiency of LBP on
by using the SPSS program and the correlation
hyperlipidemia by focusing on bone parameters and
coefficient was tested by means of the analysis of
thyroid gland hormones.
variance by complete randomized design (CRD). The
least significant difference (L.S.D) was used to show the
Materials and Method
significance of the results12.
Experiment Design: A total of 45 male albino rats
were equally grouped into three sets. The first group Results and Discussion
(G1) was fed with normal diet and considered as a
control group. The second group (G2) was fed with 2% Levels of TC, TAG, LDL, and VLDL were
cholesterol-enriched diet for three months to induction significantly higher among males in G2 compared to
of hypercholesterolemia; the third group (G3) was fed G1, while the picture was an opposite direction in the
with 2% cholesterol-enriched diet +100mg/kg of LBP. levels of HDL. Hoverer, all these measured biomarkers
Blood samples were withdrawn after starvation of the were not significantly changed in G3 rats compared to
animals at night, after the end of three months, when 5 that observed in G1 rats (see table 1)
ml of blood was withdrawn from the heart. The blood
was then placed in clean plastic tubes, especially the G2 rats had significantly greater levels of PTH,
non-containment of anticoagulants. At a speed of calcium and phosphorus, while ALP levels were
3000 cycles/minute for 15 minutes to measure some significantly reduced compared to that observed in
of the following parameters: concentration of total G1 rats. Levels of thyroid hormones (T3 and T4) were
cholesterol (TC), High density lipoprotein (HDL), Low significantly decreased, while the TSH levels were
density lipoprotein (LDL), Very low density lipoprotein significantly increased in the G2 rats compared to that
(VLDL), Triglyceride (TAG), Alkaline Phosphatase of G1 rats. However, Rats in group 3 did not reveal any
(ALP), phosphorus (p+), Calcium (Ca+) Parathyroid significant changes in all measured biomarkers comparing
Hormone (PTH), Thyronine (T3), Thyroxin (T4) and to that values measured in G1.(see table 2,3). any.
Thyroid stimulating hormone Hormones (TSH).

Table 1: Effect of Cholesterol at the level of TC, HDL, LDL, VLDL and TAG in serum of male rabbits
Groups
(G1) (G2) (G3)
Parameters
TC (mg/dl) 126.26 ± 5.14 163.18 * ± 4.28 130.10 ± 4.41
HDL(mg/dl) 35.41 ± 1.39 26.21 * ± 0.96 36.51 ± 1.08
LDL (mg/dl) 91.31 ± 2.54 102.0 * ± 3.46 94.65 ± 3.14
VLDL (mg/dl) 25.25 ± 0.92 32.63 * ± 1.05 26.02 ± 1.03
TAG (mg/dl) 139.34 ± 4.85 142.59 * ± 5.13 140.74 ± 4.91
Mean ± standard error, *= significant difference
Present study demonstrated that the high cholesterol such as the derived pre osteoblasts and oxidized low-
diet has led to boost the levels of TAG, TC, LDL and density lipoprotein (oxLDL) could negatively interfere
VLDLC and down regulated the HDL levels. These with several differentiation processes of osteoblast15.
results are agreed with many experimental tudies 13. In addition, these molecules may also suppress the
Excrescent intake of cholesterol results in elevation of differentiation of preosteoblast and mesenchymal stem
serum cholesterol concentration by down regulating cells16. In the current study, HDL levels were
LDL receptor synthesis by increase intake of LDL by significantly decreased in G2 group, suggesting that
LDL receptor which leads to elevation of blood hyperlipidemia may have caused elevation of LDL and
cholesterol concentration14. Increase levels of lipids TG together with increasing risk. Serum levels of HDL
oxidative damage has been suggested to be a mediator were inversely related to risk. This result agreed with17.
driving the osteoporosis. In bone, many of bioactive
oxidized lipids

Table 2: Effect of Cholesterol at the level of ALP, p+, Ca+ and PTH in serum of male albino rats
Groups
(G1) (G2) (G3)
Parameters
ALP(U/100 mL) 18.11 ± 4.38 12.34 * ± 0.48 16.48 ± 1.03
P+(mmol/L) 4.42 ± 2.23 5.36 * ± 1.54 4.72 ± 1.86
Ca+(mmol/L) 2.59 ± 0.17 3.61 * ± 0.24 2.58 ± 0.91
PTH(PG/Ml) 582 ± 10.34 675 * ± 9.91 597 ± 10.13
Mean ± standard error, *= significant difference
In this study we also confirm that, the high fat diet that diet with high quantity of cholesterol could have
lead to hyperparathyroidism in rats, by the elevation had negative impacts on bone functions. It may have
the concentration of PTH, Ca+ and P+. The calcium also reduced bone formation and promoted bone
measurement in the rats with high fat diet may be resorption21.
pseudohypercalcemia as the result of the turbidity of
serum riches with fats18. Hyperparathyroidism may Levels of T3 and T4 were significant decreased
result from resistance of renal PTH which leading to and there was an increase in the level of serum TSH
in treated group compared with the control group. In
retention of phosphate or a change in the calcium-
hypothyroidism, the effects of thyroid hormone on the
sensing receptor. This may be a negative feedback
expression of LDL receptor and absorption of
response due to elevation the concentration of PTH19.
cholesterol exceed the effects of the cholesterol
On the other hand, the down regulation of PTH receptor
synthsised by hepatic cells24. Greater levels of serum
could be due to detrimental effects of oxidized lipids on
lipids levels in these rats with hypothyroidism are agreed
bone cells especially the osteoblasts [20]. The increased
with many studies25,26. The abnormality of lipid in
levels of ALP observed in the current study may indicate
hypothyroidism could be linked to the changes observed
in serum TSH levels

Table 3: Effect of Cholesterol at the level of T3, T4 and TSH in serum of male albino rats

Groups Rats provided with 2%

Rats provided with Rats provided with 2%
cholesterol-enriched diet
Parameters normal diet (G1) cholesterol-enriched diet (G2)
plus 100 mg/kg LBP (G3)
T3 143.86 9.04 ± 127.83 * 4.28 ± 139.97 4.63 ±
T4 51.05 ± 3.72 22.48 * ± 4.19 48.73 4.51 ±
TSH 1.61 ± 0.21 * 4.62 1.04 ± 1.98 0.28 ±
Mean ± standard error, *= significant difference reactive oxygen species and in turn minimizing the
possible
Historically, LBP has been used as a source of
antioxidant that scavenges the potential effects of
oxidative damage. 27. The effect of LBP on cholesterol
riches diet has been tested in rats in order to evaluate its
influence on TC, its LDL, HDL and TAG levels. Rats
fed
with LBP and cholesterol were distinguished by effects of polysaccharides isolated from
increased HDL concentrations and decreased Lycium
concentrations of TC, LDL and TAG compared with
cholesterol enriched rats28. This study agreement with
many studies29 which get similar results supported the
supposition that supplementation of LBP has a positive
effect on the serum lipid by decreasing TC and TAG
concentrations. Other study demonstrated that the
hypolipidemic effect of LBPs was seen on the
hyperlipidemic rabbits. In these animals, LBPs have
significantly reduced the s total cholesterol and TAG
and increased the HDL-C levels after 10 days of treating
with LBPs, LBPs also exhibit effective antioxidant
activities against hyperlipidemia. The data from that
study highlighted the hypolipidemic and antioxidant
effects of LBP 30.

Conflict of Interest: This research is a personal non-

profit work and there is no conflict of interest.

Source of Funding: None.

Ethical Clearance: Ethical clearance was obtained from

the Faculty Scientific Committee (College of Education
for Pure Science, University of Kerbala, Iraq) to Study
the effect of Lycium barbarum Polysaccharide on bone
and thyroid gland in hyperlipidemic healthy male albino
rats.

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DOI Number: 10.5958/0976-5506.2019.01668.1

Effect of Exposure Biochinin-A During Gestation Stage on

HoxA10 Gene Expression and Histological Change in Uterus of
Healthy Female Rats

Huda A. Najy1, Ayyed H. Hassan1

1
College of Veterinary Medicine, University of Kerbala, Karbala, Iraq

ABSTRACT
The aim of this study is to estimate effect of exposure BC-A during gestation stage onHoxa10 mRNA
expression with histological change in uterus of female rats. This study include Sixty mature female rats
were meted with thirty males after making sure all female rats get pregnant. Sixty pregnant females were
divided for 5 groups each groups contain 12 female rats as fallowing (control negaative, control positive,
25mg/kg, 50mg/kg, and 100mg/kg) B.W, during gestation in 12th,14th,16th, and 18th utero –exposure to BC-
A. The pregnant rats were allowed to deliver F1 pups. Adult F1femle rats were also mated with male.
HoxA10 mRNA expression was measured by using RT-PCR procedure. Our result found the HoxA10
mRNA expression level were increased more in dose 100 mg/kg B.W. in uterus of female rats compared
with doses 25,50 mg/kg B.W. and control groups of F1 mature rats. While, there were histopathological
changes generally including uterine hyperplasia, cystic endometrial hyperplasia (CEH), congestion and
bleeding in the myometrium and enlargement in the cells lining uterine gland with reduce the number of
uterine gland. In conclusion: The BC-A is exposure to during embryonic growth in uterus leads to
changes in the level of gene expression of HoxA10 gene. As well as, lead to change in histological of
uterus, which affects the reproductive health.

Keywords: Biochinin-A, HoxaA-10, mRNA expression, phytoestrogens, cystic endometrial hyperplasia(CEH),

rats.
Introduction Perinatal presented to phytoestrogens nourishment
could be affecting on ovarian cells in the develop rodents
These days, as the responsibility on endocrine
become a few initiation material since4. Biochanin An, a
disturbance were different combinations of compositions
non-steroidal estrogen present in plant, dietary-inferred
of blend that numerous antagonistic influenced the
biochanin A mixes show different estrogenic and
humans and animals or descendants by means of
antiestrogenic consequences for estrogen-related quality
cooperate with endocrine disturbance1. Endocrine
articulation, recommending quality explicit guideline5.
upsetting are exogenous substance that meddle with
The hox quality family coordinates appropriates
hormones combination, digestion, or activity.
morphological improvement and tissue separation
Furthermore, some of them could epigenetic
along all the key hub of the embryo6. HoxA10 quality
modification of DNA that can be transmitted to the
is the organogenesis of mullerian regenerative tract.
accompanying ages. The embryo is touchy to any
HoxA10 is communicated in the uterine epithelium,
change of hormone condition2. Biochanin
stroma and muscle. In situ hybridization of HoxA10
-A an isoflavone phytoestrogens present in red clover
mRNA uncovers solid articulation in the uterus,
that
however no articulation in the fallopian tube, cervix
was a specifically agonist at ER-β estrogens receptor3.
or vagina7. In Hox A10 quality – a quality is vital
for
uterus advancement, it is fascinating to take note of that
Corresponding Author: hoxa10 DNA methylation was not adjusted in grown-up
Huda A. Najy mice treated with same of phytoestrogen, it features the
College of Veterinary Medicine, incredible defenselessness of the baby and the presence
University of Kerbala, Karbala, Iraq of basic formative window for the epigenetic impacts of
Email :[email protected] EDC8. Presentation to estrogenic synthetic substances
770 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 770

amid fetal life disturbs female conceptive tract G3: Female Rats were given Biochinin-A(IP)at dose of
developmental9. The impacts of formative introduction 25mg/kg B.W
to phytoestrogen on uterine morphology and function 10.
G4: Female Rats were Biochinin-A (IP) at dose 50 mg/
By adjustment in endometrial stromal morphology 11.
kg B.W.
Notwithstanding local differentiation, the endometrial
epithelium experiences glandular morphologensis to G5: Female Rats were given Biochinin-A(IP)at dose of
shape spread glandular structures in endometrial stroma. 100 mg/kg B.W.
These cell and provincial separation stroma. These cell
The tested compound is Biochanin-A(BC-A): The test
and territorial separation forms are stunningly delicate to chemical used in this experience is BC-A acquirement
interruption by steroid hormone singling12. from Sigma Chemical Company, USA13.
Tissue sample: For histological analysis of the uterus to
Materials & Method
organize the architecture changes and for assessment of
Animals of the Study: The experimental animal mRNA expression level of target gene (HOX10 A):
model selected for present study is (Rattus Norvegicus) 1. Histological examination: The tissues were
rats were obtained from the Laboratory Animal Unit, promptly fixed in formalin (10%). After fixation,
College of Medicine, University of Baghdad, Iraq. tissues were handled in common way and
They were 16 to 18 weeks old with an average body implanted in paraffin for consequent histological
weight (200-250gm) for females and (250-300gm) for examination of uterus. The histological area was
males. The animals were clinically healthy, kept under assessed by a pathologist earlier learning of BC-A
hygienic conditions and air-conditioned room. The light given to creatures done according to14.
system was 12/12 hrs light/dark cycle;25 ± 5 C° with a 2. Tissue preparing for expression level of
relative humidity of 50 ± 5%. Food & water were HOX10A gene: The tissues were placed quickly
offered daily, the animals were accommodated to the in normal slain then freezing in -20 c°. Total RNA
laboratory Collage of Veterinary Medicine, University extraction :Total RNA were extracted from rat
of Kerbala, Karbala, Iraq conditions for 30 days before uterus horn by using Accuzol Total RNA
beginning of experiment for acclimation then randomly Extaction Reagent(Bioneer, Korea) and done
divided into four groups comprising 12 animals for each according to15.
group as the following:
Primers: Two primers were used in this study, first
G1: Female Rats were given DMSO (IP) & served primer used for 18S gene as Housekeeping gene and
as second primer used for HOXA10 gene as target gene.
control negative These primers were obtained from16, the primers used
in quantification of gene expression using qRT-PCR
G2: Female Rats were given Estradiol (IP) at dose 5mg/ techniques based SYBER Green DNA binding dye, and
kg B.W & served as control positive. supported from (Bioneer, Korea) company.

Table 1: The Primers and their sequences

Primer Sequences (G-C) Amplicon size

F 5¢-AACAGTAAGCCTCTCGGA-3¢ 50 bp
HOXA10
R 5¢-TGCTTCGTGTAAGGGCAGC-3¢ 57 bp
Housekeeping F 5¢TAAGTCCCTGCCCTTTGTACACA-3¢ 47 bp
18s R 5¢GATCCGAGGGCCCTCACTAAAC-3¢ 59 bp

RT-PCR protocol: Get ready GoTaqR 1-Step RT- Static analysis of qRT-PCR: the information
qPCR Reaction Mix as a response blend that consequences of q RT-PCR for target and housekeeping
involvement: Go TaqR 1-Step RT-qPCR Master Mix, quality were broke down by relative evaluation quality
CXR dye, nuclease articulation levels (fold change) Livak method that
- free water and Go Script™ RT Mix. Conclude the explained by18.
numerous of control and experimental reactions in the
assay according to17.
Test Calibrator (cal) The effect of BCA on female Uterus Histology: The
Target gene CT(target, test) CT(target, cal) uterus of rat perinatal treated with BC-A in doses (25
mg/ kg,50mg/kg,100mg/kg) B.W. there was
Reference gene CT(ref, test) CT(ref, cal)
histopathological changes generally including uterine
Calibrator sample: hyperplasia, cystic endometrial hyperplasia (CEH),
congestion and bleeding in the myometrium and
ΔCT (calibrator) = CT (ref, calibrator) – CT (target, enlargement in the cells lining uterine gland with reduce
calibrator)
the number of uterine gland.
Test sample:

ΔCT (Test) = CT (ref, test) – CT (target, test)

ΔΔCT= ΔCT (test) – ΔCT (calibrator)

Fold change = 2-ΔΔCT

Ratio (reference/target) = 2CT (reference) – CT

(target)

So, the relative expression was divided by the

expression value of a chosen calibrator for each
expression ratio of test sample.

Results
Reverse transcriptase real-time PCR results
presented that HOXA10 mRNA expression level were
increased more than in dose 100mg/kg female rats
compared with doses 25mg/kg,50mg/kg and control
group of female mature rats. The results of this
calculations offered the relative expression is (8.229)
fold higher in alternative in dose 100 mg/kg. While,
in dose 50 mg/kg (5.419)
.and in dose 25 mg/kg the fold change (3.449) than in
control positive higher (3.557). Fold is lower in control
negative (1.152).in table (4-2-6). Again, in time at which
all the alternative dose of BC-A produces increased in
hoxa10 gene expression Treated groups and with each
of other groups, a matter which contribute to significant
differences at (P≤0.05).

Fig. 1: Effect of BC-A exposure on uterine HOXA10

expression was measured by relative RT-PCR in
different dose of BC-A utero-exposure
Discussion

In this present study, we have been researched

that effect of the BC-A (phytoestrogens) on hoxa10
gene expression in uterine during gestation stage to
fetus in vitro life’s results in changed in reproductive
dysfunctional via changing HoxA10 expression. In
present study have been alteration in HoxA10
expression in various doses due to effect of BC-A, the
higher dose
100mg/kg cause uterine histology, hypertrophy and
disrupt female fertility. The HoxA10 is important for
continuing adult expression in stroma, muscle, uterus
and epithelium gland also in normal development of
mullerian duct19. The HoxA10 was activated by steroid
hormone when bind to endometrial receptor that lead to
regulation cell differentiation, it caused on endometrium
responsive to embryonic development20. The HoxA10
is a basic of development immure mesenchymal cell
to endometrial tissue21. Estrogen is a potent promster
of HoxA10 gene through stimulation of stroma and
endometrial during control steroid hormones during
development stage22. The growth and development of
female fetus is very sensitive to any components or
compounds estrogens23. The exposure to BC-A during
pregnancy effects on development and growth of uterus
and this similar when treated neonataly or
during
Fig. 2 pregnancy to DES . The HoxA10 gene expression
A: Light micrograph of histological changes in in 50mgkg B.W, (black arrow) cystic endometrial
normal uterus of female rats (green arrows) shows hyperplasia (CEH). H&E, 10x.
normal in cells lining endometrium and uterine
gland. H&E, 10x.
B: Light micrograph of histological changes in
uterus of female rats perinatal exposed to BC-A in
100mgkg B.W shows the (yellow arrow) uterine
hyperplasia
in endometrium of uterus. (black arrow)
cystic endometrial hyperplasia (CEH). H&E,
10x.
C: Light micrograph of histological changes in
uterus of female rats perinatal exposed to DES
control positive. shows (black arrow) enlarged cell
lining uterine gland. H&E,10x.
D: Light micrograph of histological changes in
uterus of female rats perinatal exposed to BC-A
in 25mg/kg B.W shows the (yellow arrow) uterine
hyperplasia in endometrium of uterus (black arrow)
enlarged cell lining uterine gland. H&E, 10x.
E: Light micrograph of histological changes in
uterus of female rats perinatal exposed to BC-A
2
4

during exposure to BC-A to BC-A appears to

associated with uterine dysfunction. Gene expression
is assign of hormonal imbalance. The histologic
evaluation of uterus25. In the present study where
exposed perinatal to BC-A in different dose
(25,50,100) mg/kg B.W. We have been shown the
bad effect of BC-A on the activity of estrogen leading
to dysfunction in female reproduction system. Light
micrograph of histological changes of the uterus rat
perinatal treated with BC-A in doses (25
mg/kg,50mg/kg,100mg/kg) B.W. there were
histopathological changes including cystic endometrial
hyperplasia (CEH), bleeding in the myometrium
uterine, hyperplasia, congestion and enlargement in the
cells lining uterine gland with reduction the number of
uterine gland with enlargement of cell lining uterine
gland and uterine hyperplasia in endometrium. The
incidence of uterus lesions was described, and this is
in accordance with the recent data on the potentially
carcinogenic alterations in female reproductive tissues
caused by decrease pre-natal doses of xenoestrogen14.
The exposure to DES during critical stages of
pregnancy lead to reprogramming of uterus and this
responsible
for changes in the level of estrogen during a lifetime 26. C. The role of the Hoxa10/HOXA10 gene in the
The exposure to BC-A during uterine organogenesis etiology of endometriosis and its related infertility:
cause changes in level of DNA and increases the a review. Journal of assisted reproduction and
gene expression of estrogen receptors as ERβ in the genetics, (2010). 27(12), 701-710.
endometrium27. This may increase height of endometrial
8. Bromer, J. G., Zhou, Y., Taylor, M. B., Doherty,
epithelia28.
L., & Taylor, H. S. Bisphenol-A exposure in utero
Conflict of Interest: This research is a personal non- leads to epigenetic alterations in the
profit work and there is no conflict of interest. developmental programming of uterine estrogen
response. The FASEB Journa,l(2010). 24(7),
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DOI Number: 10.5958/0976-5506.2019.01669.3

Prevalence and Associated Risk Factors of Forward Head

Posture among University Students

Vinodhkumar Ramalingam1, Ambusam Subramaniam2

1
MPT (Sports Physiotherapy), Senior lecturer, 2MSc (Health Sciences), Lecturer, FHLS, Physiotherapy,
INTI International University, Persiaran Perdana BBN, Putra Nilai, 71800 Nilai, Negeri Sembilan,
Malaysia

ABSTRACT
Background: There is an increase of forward head posture among university students due to faulty posture
in their daily activities. Age, gender, usage of computer and smart phones are one of the contributing
factors of forward head posture.
Methodology: This cross-sectional study was conducted to determine the prevalence of forward head posture
and to investigate the associated risk factors that contribute to the development of forward head
posture.
188 participants were recruited in the current study with pre-defined inclusion and exclusion criteria. The
participants were screened with demographic questionnaire, followed by the cervical angle measurement
using photography method. Then, the angle measurement was analyzed using web plot digitizer (WPD)
software.
Results: 67 % of participants were identified with forward head posture while 58.5% were not aware of
forward
head posture. Only computer and smart phones showed significant association with forward head posture.
Conclusion: There is a need of intervention and education on awareness of good posture especially
with
increased usage of computer and smart phones in recent days.
Keywords: forward head posture, computers, smart phones, risk factors, university
students
Introduction MSc (Health Sciences), Lecturer, FHLS, Physiotherapy,
INTI International University, Persiaran Perdana BBN,
Forward head posture has been identified as the Putra Nilai, 71800 Nilai, Negeri Sembilan, Malaysia
displacement of the head anteriorly with cranio-vertebral Email: [email protected]
angle lesser than 50 degrees. (1,2) While the head
displaced forward, the centre of gravity also shift and
consequently, causes the upper body to shift backward
with the shoulder slumped. (3–5) Sustaining the head in
this forward posture for prolonged period of time has
been associated with the development of other
musculoskeletal disorders such as ‘upper crossed
syndrome’, which leads to reduction of lordosis in lower
cervical and kyphosis of upper thoracic vertebra. (6,7) In
the long run, this may cause shortening of muscular
fibers muscles involving the atlanto-occipital

Corresponding Author:
Ambusam Subramaniam
articulation, overstretching of muscles around joint and
leads to chronic neck pain. (8)

In a study among university students in Pakistan,

prevalence of 63.96 % of forward head posture were
reported. (1) Whereas in another study among dental
staff, 85.5 % reported of forward head posture. (9) In
another study among healthy subjects, 66 % reported
of forward head posture and they fall under the age
range of 20-60 years old. (10) The increase of forward
head posture at alarming rate especially among young
adults is worrisome. Nevertheless, there is no evidences
on the prevalence rate of forward head posture among
students in Malaysia. Hence, there is a need for a study
to determine the prevalence of forward head and an early
intervention in preventing the faulty posture.

There are many factors that could contribute to the

development of forward head posture such as age(10),
gender (11–14), frequency of physical activity (15,16),
occupation (4), usage of computer and smartphones (4,17)
and others. However, there is lack of literature
addressing the prevalence of forward head posture
among university
776 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 776

students in Malaysia. Besides, no studies have examined a horizontal line through the spinous process of C7 using
all the associated risk factors together that influence the WPD software [Figure 1]. (19,21) Forward head
development of forward head postures. Thus, the aim
of the current study is to determine the prevalence of
forward head posture and to investigate the associated
risk factors that contribute to the development of
forward head posture among university students.

Methodology
Subjects: A cross-sectional study was conducted to
determine the prevalence of forward head posture
among university students. This study was conducted
among four private universities in Klang Valley,
Malaysia with total of 188 participants thru convenience
sampling method. The participants were selected with
predefined inclusion and exclusion criteria. Selected
participants were between the age of 18 to 30 years
with good general health. Participants with history of
cervical and shoulder fracture or trauma, cervical
surgery, functional or structural scoliosis, bone cancer or
had excessive thoracic kyphosis were excluded from the
study. (18–20)

The first author briefed the study methodology to the

participants and written informed consent was obtained
prior to the study. The Research Ethics Committee of
INTI International University, Malaysia approved the
study.

Procedure: The participants were given a demographic

questionnaire that includes, age, gender, BMI, usage of
computer and smart phone daily as well as the awareness
towards forward head posture. The C7 spinous process
was palpated and identified with a marker which was
attached over its midpoint of the most prominent part.
The participants were then instructed to stand at their
comfortable stance and not allowed to shift their body
weight from one foot to another. Participants were
required to flex and extend the head for three times and
then look forward while resting in a comfortable position.
(18)

Participant’s cervical angle were analyzed by taking

a photo from the sagittal view. The measurement was
standardized as the distance from the participant’s
shoulder tip to the center of the camera were set at 30cm
in standing position. (20) The photos were transferred to
the computer and analyzed using Web Plot Digitizer
(WPD) software, an open resource, used to retrieve
quantitative data from images (http://arohatgi.
info/WebPlotDigitizer/). The cervical angles were
quantified according to previous study angle
measurement methods with a virtual line was drawn
between the midpoint of tragus to C7 spinous process and
777 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 777
posture was indicated with high decrease in the
cervical
angle measurement.(22–24).

Figure 1: Reading from WPD software represents

craniovertebral angle when two indicator lines were
aligned with pin markers (seventh cervical [C7]
vertebra spinous process) and tragus

Statistical Analysis: Data were analyzed using statistical

software package SPSS (Version 21.0, Chicago, IL,
USA). The data were normally distributed based on the
Shapiro- Wilk test. Descriptive statistics were used to
examine the prevalence and awareness on forward head
posture among the university students using frequencies.
A Chi-square test was employed to investigate the
relationship between forward head posture and risk
factors such as age, gender, computer and smartphone
usage daily.

Results
Prevalence and Awareness of Forward Head Posture:
In the current study, 67% participants were identified
with forward head posture. Based on the WPD analysis,
the highlighted green group indicates participants with
minimal or non-FHP (≥55º cervical angle) whereas the
red group indicates severe FHP with <50º of cervical
angle. Participants with moderate FHP falls under
cervical angle 50º - 54º of CV angle [Figure 2]. The
results also reveal that 58.5% participants were not
aware about the forward head posture. The mean (SD)
of the participant’s age were 20.12 (2.19).

Forward Head Posture and Age: The age distribution

was shown in Figure 3. Results revealed that most of
the participants with forward head posture were aged
between 18-21 (45.2%). The results of the Chi-square
demonstrated that there was no significant association
between age and forward head posture (p = 0.625).

Forward Head Posture and Gender: The number

of male and female participants was 74 and 114.
The
prevalence of forward head posture (moderate and per day have shown high number of forward head
severe posture prevalence. The Chi – square analysis
category) among male and female participants was demonstrated significant association between duration of
67.57% (50/74) and 66.67% (76/114) respectively. The computer use daily and forward head posture (p =
results show that the prevalence of forward head posture 0.000).
among male participants is slightly higher than female
participants. The Chi-square analysis demonstrated no Forward Head Posture and Usage of Smart Phone
significant association between gender and forward Daily: The prevalence of forward head posture
posture (p = 0.991). (moderate and severe category) among the participants
of smart phone use daily between 1 to 5 hours were
Forward Head Posture and Usage of Computer 23.38% (18/77), 6 to 10 hours were 95.16% (59/62),
Daily: The prevalence of forward head posture 11 to 15 hours were 100% (41/41) and more than 15
(moderate and severe category) among the hours were
participants of computer use daily between 1 to 5 100% (8/8) respectively. Similar to computer usage,
hours were 41.9% (44/105), smart phone usage of more than 6 hours per day also
6 to 10 hours were 98.3% (59/60), 11 to 15 hours were shows high number of forward head posture prevalence.
100% (21/21) and more than 15 hours were 100% (2/2) There is a significant association between smart phone
respectively. The use of computer of more than 6 hours usage and forward head posture (p = 0.000).

Figure 2: Scatter Plot showing CV angle of each participants

Figure 3: Age distribution of participants

Discussion The limitation of current study is the generalization
duration usage of computer and smart phone in the
The prevalence of forward head posture among 188
university student in the current study is 67%
whereas
58.5% of student reported not aware of forward head
posture. In another similar study conducted by Arfa et
al. among 197 students from four universities in
Pakistan, the prevalence of forward head posture was
63.96%. The same study concluded that the high
prevalence among the university student could be
possibly due to high usage of computers and faulty
postures during lectures.(1)

The current study reveals no significant association

between forward head posture and age, although a high
percentage of 45.2% of participants aged between
18
– 21 reported of forward head posture. This could be
possibly due to the usage of computer and smart phones
more in this university age range compared to others.
(10)
There is a significant relationship between computer
and smartphone usage with forward head posture in our
current study. Previous study has stated that with the
increase usage of computers located below eye sight for
prolong period of time causes exaggerated anterior curve
in lower cervical vertebra and exaggerated posterior
curve in upper thoracic vertebra establishing the forward
head posture. (4,25) These symptoms are more prominent
with the increase of smart phones usage among youth. (4)
In the long run, with the protrusion of head forward and
shift of centre of gravity anteriorly consequently will
lead to posture imbalance and reduced motor control
ability of the individuals.

The usage of smart phone in a sustained, static

posture with an unsupported arm could induce
misalignment of neck and shoulder. (17) This is being
further explained where the usage of small monitors of
smart phones with the device held on the laps causing
the individuals to position their head down, increasing
the muscle activity in the cervical extensors and
eventually triggering muscle fatigue. (26) In fact, many
previous studies have also reported positive association
between the usage of computer and smart phones with
forward head posture similar to our study. (17,26,27)
Therefore, the current study emphasizes the importance
to create an awareness on the correct posture and
consequences of forward head posture in the long run as
prolong use of computer and smart phones may induce
changes in cervical and even the thoracic and lumbar
spine posture.
questionnaire as in if the students used the devices for
social media, assignment used, entertainment or gaming
purpose in the questionnaire. Future studies should
examine the responsiveness of the WPD software in
longitudinal study for better accurate reliable result.
The ability to identify the cervical angle might differ
time to time, thus, future studies focusing over the same
participants over a length period of time is suggested.

Conclusion

A high prevalence of forward head posture has been

identified in the current study among the university
student. The current study also indicates a significant
association between the computer and smart phone
usage with forward head posture. The significant forward
head posture differences between these students needed
to be intervened as it may affect the health in future.
This study, hence, provides evidence for existing data
and further emphasize the importance of good posture
education and physical exercises for the students.

Acknowledgements

The authors sincerely thank all the participants in

the current study.

Conflict of Interest: No potential conflict of interest

was reported by the authors

Source of Funding: Self

Ethical Clearance: The Research Ethics Committee of

INTI International University, Malaysia approved the
study.

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DOI Number: 10.5958/0976-5506.2019.01670.X

Exploration of Patients Value as in Accordance with Bugis

Philosophy in Public Hospital at the Sulawesi Selatan,
Indonesia

Armin1, Indahwaty Sidin2, Indrianti Sudirman2, Harun Achmad3

1
Doctoral Program of Science of Public Health; 2Department of Hospital Management, Faculty of Public
Health;
3
Department of Pedodontic, Hasanuddin University, Faculty of Dentistry, Hasanuddin University,
Indonesia

ABSTRACT
In this new era of globalization, Business organizations around the world are struggling to develop effective
quality measurement parameters, and strategies to survive in competition, and to achieve customer
satisfaction, business organizations such as hospitals must be able to understand the needs, desires and
expectations of customers and be able to create value. This study aims to explore the value of patients
according to Bugis Philosophy at the Regional Public Hospital in South Sulawesi. The study was
conducted at 4 hospitals in
4 regency where the majority of the population were ethnic Bugis namely Siwa Regional Public Hospital
WajoRegency, LamadukellengRegional Public Hospital SengkangRegency, TenriawaruRegional Public
Hospital Bone Regency and AndiMakkassau Hospital Pare-Pare City in South Sulawesi Province. The
research method is qualitative. The results of this study indicate that identification of customer needs in terms
of health care services is good even though medical devices are not complete. The underlying reason for
patients to choose treatment is mostly because the distance is close enough, good and complete health
services, and referral factors from the health center.Health services that should be available in hospitals are
improving health services that are prime for all aspects both in terms of nurse care and doctor’s vision.The
types of services or other supporting facilities needed are still lacking, and presumably the hospital allows
families to come to visit even though briefly. The conclusion of this study is that patients’ needs related to
health services from all aspects are classified as not running optimally because it is caused by several factors
such as lack of health human resources (expert doctors), incomplete health equipment, and other supporting
facilities that are not yet available. (Marenrengperru’) between families within the scope of the region it is
advisable to maintain the existing bugis values without violating the rules that apply within the scope of the
hospital.

Keywords: Value, patients, Regional Public Hospital, Bugis

Philosophy,
Introduction Department of Pedodontic, Hasanuddin University,
Faculty of Dentistry, Hasanuddin University,
In this new era of globalization, business Indonesia Phone: 085242739400
organizations throughout the world are struggling Email: [email protected]
to develop effective measurement tools for quality
measures, and strategies for survival in competition.1
With increasing competitive competition in the
global
economy, profitability, requiring more than good

Corresponding Author:
Harun Achmad
products and services, a business must provide
customers with unforgettable satisfaction. 2 The health
industry is considered to be one of the most challenging
sectors in the face of increasing pressure in the health
sector, and the introduction of new technology needs
attention in its implementation.3

On the one hand, the development of information

technology makes people more intelligent and demands
superior service quality.4 This is also influenced by the
number of service options presented which are marked
by the development of the hospital industry. Modern
hospital management systems must provide customer
focused services, which means that the hospital must be
able to understand the needs, desires and
expectations
782 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 782

of customers and creating valuein providing services technique of collecting data with indepth interviewsand
in order to achieve satisfaction and be able to survive observationsfor inpatients during November-December
competition.5 2018 as informants.

The results of research show that trust in satisfaction

is smaller than the indirect effect of trust in satisfaction Results
through customer value. This is also supported by the A. Characteristics of Informants The: Number of
results of research conducted by Indrianty which shows informants was 32 people from 4 Regional Public
that the dominant variable to increase the lifetime value Hospitals in South Sulawesi, consisting of 13
of customers for the public is the brand equity value for male and19 female. In this research the theme was
public hospitals, while those in private hospitals do not compiled based on the purpose of the research,
show a significant difference. 6,7 namely identifying customer needs in accordance
with the philosophy of Bugis in this case the
South Sulawesi Province which has various tribes patient with ethnic Bugis in several Regional
and languages i ncluding ethnic and Bugis languages. Public Hospitals in South Sulawesi Province.
Bugis language is one of the language groups spoken in
the Bone area to Pinrang, Sinjai, Barru, Pangkep, Maros, B. Identification of Customer Needs
Pare – Pare,Sidrap, Wajo, Soppeng, this language is the a. for Health Workers in
language most used by the people of South Sulawesi.In 1. SiwaRegionalPublicHospital,WajoRegency:
Bugis tribal culture there are three things that can give Experience informants on services provided by
an idea of t he culture of the bugis, namely the concept health workers both doctors and nurses while
of ade, sirinapesseand the symbolism of the bugis is the being treated at the Regional Public Hospital
silk sarong.8 of WajoRegency. From the interviews, some
opinions were conveyed by the informants,
Bugis ethnics that have theideologySiri Na most of whom said that the services provided
Pecce which include the existence of the nature of by doctors and nurses at SiwaRegional Public
Sipakalebbi(sipklEbi) which is horizontal mutual respect Hospital were good and they served quickly
including Ada Na Gauk(ad ngau)namely words according and friendly even though the medical devices
to deeds, Teppe (tEpE) namely belief, acknowledging were not complete but still made patients feel
self-servantSipakatau (sipktuuau) namely mutual respect, comfortable.
mutual respect as servants (humanity), Mamase (mmes) 2. TenriawaruRegional Public Hospital,
which is friendly in speaking, always showing affection, BoneRegency: Experience of informants on
Malempu(mlEuuPu) u are honest, honest,macca(mc), the services provided by health workers both
which is smart, smart MarenrengPerru (mereREpru) doctors and nurses while being treated at the
which is faithful, symbolizes a very close family Tenriawaru Regional Public Hospital in Bone
relationship.9 Regency. From the results of the interviews,
several opinions were conveyed by the
Based on the above, cultural aspects need to be
informants, namely all informants said that the
considered in providing daily services at the Hospital.
services provided by doctors and nurses were
This study will explore the needs of patients according to
good and they served kindly and quickly.
value through the service experienceof ethnic Bugis
patients at the South Sulawesi Regional Public Hospital. 3. LamadukellengRegional Public Hospital,
The focus of the research lies in exploring the needs of Sengkang Regency: Services provided by
doctors and nurses are good and they serve
patients for the Regional Public Hospital in South
fast, responsive, friendly and polite especially
Sulawesi based on local wisdom, namely Bugis
the doctors and nurses are diligent to visite,
philosophy.
even though the ICU is not conducive because
visitors are smoke-free in the ICU, but do not
Materials and Method reduce patient satisfaction at the hospital. From
the results of the interviews, several opinions
Type of research used is descriptive qualitative
were conveyed by the informants.
research with anapproachethnographic. Samples were
taken based on the minimum number of needs with the
4. AndiMakkassau Hospital, Pare-Pare City: improvement of primary health services related
From the interviews most of the informants said to doctors being more patient to patients and
that the given at AndiMakkassau Hospital, Pare- visite time in the morning.
Pare City is pretty good and they serve quickly. 2. TenriawaruRegional Public Hospital, Bone
b. Reasons for Selection of the Hospital as a Regency: Health services that should be
place Treatment available at the hospital are improved health
1. Siwa Regional Public Hospital in services for all aspects. From the interviews,
WajoRegency: The underlying reason for some opinions were conveyed by informants,
informants to choose SiwaRegional Public most of whom said that the health services that
Hospital as a place of treatment is mostly should be provided by doctors and nurses at
because it is close to home, good service, the TenriawaruRegional Public Hospital were
complete specialist doctors and referral factors the improvement of their main health services
from the Puclic Medical Center. related to doctors being more patient and visite
2. Tenriawaru Regional Public Hospital Bone time in the morning.
Regency: The underlying reason for the 3. LamadukellengRegional Public Hospital,
informant was to choose Tenriawaru Regional Sengkang Regency: Health services that
Public Hospital mostly because they already should be available in hospitals are to improve
had experience in the hospital, besides also the quality of excellent health and nursing
because of the complete medical doctors, health services and maintain performance.
complete medical devices, good service and From the interviews, some opinions were
due to reference factors. conveyed by informants, most informants said
3. LamadukellengRegional Public Hospital, that health services should be provided by
Sengkang Regency: The reason for choosing doctors and nurses in LamadukellengRegional
LamadukellengRegional Public Hospital, Public Hospital, Sengkang Regency, whose
SengkangRegency for treatment is because quality of health and nursing services was
the distance is quite close, good service, related to doctors as much as possible to visit
complete specialist doctors, friendly nurses, patients, quickly and responsive in serving
and complete health services. The following is other than that the hospital tightened the rules
an interview quote about this. regarding smoking bans for buyers.
4. AndiMakkassau Hospital, Pare-Pare City: 4. AndiMakkassau Hospital Pare-Pare City:
The reason underlying the informant for Health Services what should be available at the
choosingAndiMakkassau Hospital of Pare- hospital is improving the quality of excellent
Pare City for treatment is because the distance health services and increasing care for nurses.
is quite close, good and complete health From the results of the interviews obtained
services, a complete specialist doctor, and several opinions conveyed by informants
already classified as type B which is certainly namely Most of the informants said that health
one of the referral center hospitals. services should be provided by doctors and
c. Health services that should be available at nurses in theAndiMakkassau Hospital of Pare-
the Hospital Pare City is to improve the quality of health
1. SiwaRegionalPublicHospital,WajoRegency: and nursing services.
Health services that should be available in d. Patient Experience During Care at the
hospitals are improved health services for all Hospital
aspects. From the interviews, some opinions
1. SiwaRegionalPublicHospital,WajoRegency:
were conveyed by the informants, most
Various patient experiences during
of whom said that the health services that
hospitalization are very diverse. From
should be provided by doctors and nurses
the results of interviews conducted, some
at SiwaRegional Public Hospital were
experiences were conveyed by informants,
the
namely informants who said that the e. Types of services or other supporting
experience of patients related to the services facilities needed by
provided while being treated at SiwaRegional 1. Siwa Regional Public Hospital, Wajo
Public Hospital is more attention to the
Regency: Various suggestions related to the
equipment available at the hospital so that
types of services or other supporting facilities
everything functions properly such as oxygen
needed but not yet available in hospitals,
cylinders
especially SiwaRegional Public Hospital so far
2. TenriawaruRegional Public Hospital, Bone are still lacking, and hospitals should complete
Regency: Patients’ experiences while being facilities so that patients feel more comfortable
treated in hospitals are very diverse. From while being treated. From the results of
the results of interviews conducted, some interviews conducted, most of the informants
experiences were conveyed by informants. said that other types of services/supporting
Some informants said that the experience of facilities needed at the SiwaRegional Public
patients related to the services provided during Hospital were still lacking so far, and the
treatment at the Tenriawaru General Hospital hospital should complement these facilities.
was the doctor’s lack of attention to visit 2. Tenriawaru Regional Public Hospital, Bone
the patient, besides the visiting hours at the Regency: Various suggestions regarding the
hospital were good so does not interfere with types of services or other supporting facilities
the patient’s resting hours, and one informant needed but not yet available in hospitals,
said that the hospital should not differentiate especially TenriawaruRegional Public
services between Health Insurance (BPJS) Hospital, BoneRegency has so far been quite
patients and general patients. good and already complete and make patients
3. LamadukellengRegional Public Hospital, feel comfortable.
Sengkang Regency: Various experiences 3. Lamadukelleng Regional Public
of patients while being hospitalized are Hospital, Sengkang Regency: Various
very diverse. From the results of interviews suggestions regarding the types of services
conducted, some experiences were conveyed or other supporting facilities needed but
by informants, namely patient experience not yet available in hospitals, especially
related to the services provided while being LamadukellengRegional Public Hospital,
treated at LamadukellengRegional Public Sengkang Regency, so far have been quite
Hospital, Sengkang Regency, good service and good, and the hospital should complete
able to maintain the quality of existing health facilities such as water supply and additional
care rooms stays can be given barriers such as
services and improved for all aspects both in
curtains so that patients feel more comfortable
terms of nurse care, doctor’s vision, and
while being treated in LamadukellengRegional
visiting hours are tightened
Public Hospital, Sengkang Regency
4. AndiMakkassau Hospital Pare-Pare
4. AndiMakkassau Hospital, Pare-Pare City:
City: Various patient experiences while
Various suggestions regarding the types of
in hospitalization is very diverse. From
services or other supporting facilities needed
the results of interviews conducted, some
but not yet available at the hospital especially
experiences were conveyed by informants,
AndiMakkassau Hospital, Pare-Pare City
namely the experience of patients related to as far as this is good enough, it’s just that
the services provided while being treated at the hospital should equip facilities such as
theAndiMakkassau Hospital of Pare-Pare City, fans or air conditioners need to be added
a good service and able to maintain the quality and cleanliness is maintained so that patients
of existing health services and improved for all feel more comfortable while being treated
its main aspects nurses and applicable rules can byAndiMakkassau Hospital, Pare-Pare City.
be applied properly.
Opinions related to the extended family who came to LamadukellengRegional Public Hospital, Sengkang
visit (MarenrengPerru’) (mereREpru) Regency and AndiMakkassau Hospital, Pare-Pare
1. Siwa Regional Public Hospital, WajoRegency: City needs of patients related to health services from
Opinions of informants regarding large families all aspects classified as not yet running with optimally
who came to visit and there were limits to because it is caused by several factors such as lack ofS
visiting hours were considered good enough, health human resources (expert doctors), incomplete
only the hospital allowed the families who came health equipment, and other supporting facilities that are
to visit all of them even though briefly because not yet available. In addition, because of the still high
of mutual caring between families was still high value (Marenrengperru’) (mereREpru) between families
(Marenrengperru’) (mereREpru). within the region, it is advisable to maintain existing
bugis values without violating the rules that apply within
2. TenriawaruRegional Public Hospital, Bone the scope of the hospital.
Regency: Opinion of the informants related to
the extended family who came to visit and there Conflict of Interest: There is no conflict of interest
are limits to visiting hours as far as This was in
considered considered to be lacking, it was better this study.
for the hospital to add visiting hours and it would
Source of Funding: Domestic government
be possible to allow the families who came to
visit even though for a while because of mutual Ethical Clearance: This study obtained a label of ethics
caring between families (Marenrengperru’) escaped by the number:1466/UN4.14.8/TP/02/02/2019
(mereREpru). on April 13, 2018
3. Lamadukelleng Regional Public Hospital,
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DOI Number: 10.5958/0976-5506.2019.01671.1

Validation of the Emotional Competency Module

Asma Perveen1, Nurul Ain Hidayah Abas1, Hazalizah Hamzah2, Pau Kee3, Ebru Morgul4,
Fauziah Binti Mohd Sa’ad5, Pavithrah Jaya Kumar6
1
Senior Lecturer, 2Senior Lecturer, Head of Department, 3Senior Lecturer, Department of Psychology and
Counseling, Sultan Idris Education University, UPSI, Perak, Malaysia; 4Lecturer, Department of
Psychology, Ibn Khaldun University, Turkey; 5Senior Lecturer, Department of Psychology and
Counseling, Sultan Idris Education University Perak, Malaysia; 6Masters in Science (Psychology) student,
Department of Psychology and Counseling, Sultan Idris Education University, Perak, Malaysia

ABSTRACT
This study is a design and development-based research which intends to develop a module specifically to be
implemented on adolescents to help enhance their emotional competence and also to test the content
validity of the module. Seven professionals with experience in dealing with adolescent emotional issues
were recruited to validate the module. A rating scale based on this is constructed to be evaluated by the
professionals. The overall validity was calculated based on the percentage of agreement between the
professionals. The Emotional Competency Module received an overall validity rating of 85.6%. Therefore,
there is evidence that shows that this module is suitable to be implemented to enhance the emotional
competency level of adolescents.

Keywords: Emotion competency, Emotional Competency Module, validity

Introduction let this go. In addition, this does not include the number
of hotspot schools identified in Malaysia with many
A recent study on adolescent delinquency found that
delinquent behaviours detected among their students.
adolescents with better emotional intelligence had lower
These delinquent behaviours are such as drug abuse,
levels of delinquency[1]. Numerous social problems
smoking, vandalism, bully among many others. Hence,
happen today that start from less serious cases such as
a module is developed to help to address these issues
coming late to school, skipping class, breaking rules,
among adolescents. Many studies showed that emotional
followed by serious cases such as disobeying teachers,
intelligence programmes or trainings were effective in
smoking, participating in illegal racing, gangsterism,
many facets such as positive emotional intelligence
bullying and more serious cases such as involving
shifts and others behaviors [5] enhance emotional
in sexual activities, pregnant out of wed lock, baby
intelligence through expressive writing and deep
dumping and rape that has been reported by the mass
breathing, increase emotional intelligence in
media almost every day[2].
adolescents with emotional and behavioral problems .[6]

Research Background: From the year 2009 to 2013,

Problem Statement: We keep observing adults
the Malaysian Welfare Department revealed that there
saying these common labels for adolescents these
are a total of 23,950 male and 1828 female offenders [3]. days such as ‘disobedient’, ‘incorrigible’, ‘unruly’ or
The Department of Statistic Malaysia reported that ‘ungovernable’. These social illnesses faced by young
Malaysian adolescent population from the age of 10 generations demand the governable attention of various
to 19 years old was estimated to be 5.5 million while individuals as there is a link between their current
the population of Malaysian youths aged 15–25 behaviour and the potential for delinquency and future
years old was estimated to be around 5.2 million and involvement in criminal activities[7]. Recently, there are
approximately 19% of the total population[4]. Although, many studies conducted based on experimental design
the number of delinquent juveniles is not high, the that implemented training or intervention to develop
number is still alarming and significant enough to simply emotional intelligence. However, very little
researches
788 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 788

have been done on emotional intelligence module Other emotional problems intervention studies
development in Malaysia. Therefore, this study intends managed to maintain the positive effects and prevent
to fill up the gap by developing a module specifically violence among adolescence in terms of use of
to be implemented on adolescents to help enhance their aggressive strategies to resolve conflict was significantly
emotional competence. reduced[11] whereas emotional competence were found
to be significant predictors of changes in perceived
Research Objective: This study aims to develop an
stress, mental health, somatic complaints and vigour and
emotional competency module for adolescents and to
confusion[12].
test the validity of the module to be implemented for
adolescents in Malaysia. Hence, the research objectives
for the study are as stated: Methodology

i. Is there any content validity evidence for Strategy This study is a design and development research.
1: Self-Awareness? An Emotional Competency Module was developed for
adolescents. Hence, to check for the content validity,
ii. Is there any content validity evidence for Strategy
the module was sent to be validated to 7 professionals
2: Self-Management?
with experience in dealing with emotional issues
iii. Is there any content validity evidence for Strategy among adolescents and also in developing modules[13]
3: Social Awareness? [14]
. According to Yaghmale (2003), having around 5
to
iv. Is there any content validity evidence for Strategy
10 field experts is more suitable to measure the content
4: Relationship Management?
validity[15].

Literature Review Research Sampling: The samples of this study

consisted of 7 professionals with experience in handling
Emotional intelligence is a combination of adolescents with emotional or/and delinquent
competencies that allows an individual to be aware of, to behaviours. Five of them are counselling or psychology
understand and to be in control of their own emotions, lecturers from Sultan Idris Education University,
to recognize and understand the emotion of others, and National University Malaysia, International Islamic
to use this knowledge to foster their own success and University Malaysia and Putra University of Malaysia.
the success of others[8]. A person who can manage their Meanwhile, other experts who were recruited worked at
behaviours, face changes, can solve problems, capable a setting in which they have to deal with adolescents
of building good relationships with others during behaviours. Some of them include a counselling teacher
worrying situations and can communicate with others at a secondary school, a Welfare Department Assistant
are those with high EQ[9]. The current study follows the Officer and a psychology officer at a juvenile delinquent
Goleman’s Emotional Intelligence Theory. Although rehabilitation center.
Goleman’s theory is more applicable within organization
setting but his theory focuses on a wider area in an Research Instruments: There are three criterias for
individual’s emotional intelligence. His theory includes checking for validity of items which are, a) The content
the four constructs of emotional competence which are measures what it’s supposed to measure, b) The items
self-awareness, self-management, social awareness and do not underrepresent the content required, c) Items
relationship management. Therefore, the module is represent what the researcher meant to measure[16]. A
mainly constructed using the Goleman theoretical rating scale based on this is constructed to be evaluated
framework. by the experts. This rating scale was back-to-back
translated and underwent face validity before it was
Meanwhile, findings from a survey showed that given to the experts.
many higher education students agreed that financial
support lead to stress and that a module to deal with Data Analysis
emotional problems was necessary [10]. Besides, 86% of
the students at the university mentioned that a module An inter-rater reliability analysis for the 7 experts
is needed to address the emotional issues that university ratings was conducted. The results showed that the
students are facing. reliability of the experts ratings was high. A descriptive
analysis was conducted based on the percentage of
rating
for each activity as well as the overall module by the experts. The results are stated in the research findings. A
validity
rating of 70% for the content validity of a module is considered high[17][18].

Research Findings

Table 1: Content validity analysis results of module activities

Percentage of
Activity: Theme Total Score
Validity (%)
Theme 1: Self-Awareness 342 81.43
1 The Emotional Brain: Psycho-biology of emotions 55 78.57
2 Emoticons: Understanding emotions 56 80.00
3 ABC: Emotion rationalization 57 81.43
4 This Is Me: Self-acceptance 57 81.43
5 Triple Vision: Self-efficacy/Resilience 56 80.00
6 The Best Version of Yourself: Self-esteem 61 87.14
Theme 2: Self-Management 507 80.48
1 Emotional Map: Emotion regulation 57 81.43
2 Breathing Technique: Controlling emotions 58 82.86
3 POP!: Stress management 52 74.29
4 Pressure Cooker: Stress management 59 84.29
5 Time Flies: Stress management/Time management 55 78.57
6 My Spiritual Coping: Stress management 56 80.00
7 Progressive Muscle Relaxation: Stress management 57 81.43
8 Weigh Me Up: Self-motivation 57 81.43
9 Move It!: Self-motivation 56 80.00
Theme 3: Social Awareness 281 80.29
1 One Day: Social responsibility 56 80.00
2 Empathy: Empathy 58 82.86
3 Colourful Emotions: Empathy 59 84.29
4 Life Tree: Social respect 55 78.57
5 Colours of Malaysia: Social respect 53 75.71
Theme 4: Relationship Management 286 81.71
1 Sherlocking: Communication skills 55 78.57
2 Let’s Win: Assertive skills 58 82.86
3 Maze Runner: Teamwork 56 80.00
4 Rabbits and Hyenas: Dealing with criticism 60 85.71
5 Sorry Sorry: Emotion expression 57 81.43

Table 1 shows that all the module activities has a high percentage of content validity results. Overall, the ‘POP!’
activity in the self-management theme received the lowest percentage of validation rating which is 74.29% whereas
‘The Best Version of Yourself’ activity which focuses on enhancing self-esteem received the highest rating which
is 87.14%. Obtaining 70% for the content validity of a module is considered high[19]. Hence, all the activities are
accepted and presumed to be effective in enhancing the self-awareness, self-management, social awareness and
relationship management skills of participants.
Table 2: Overall module validity analysis results
Overall Module Content Validity Results Percentage
1 This module covers for the target population. 84%
2 This module can be implemented successfully. 88%
3 Time allocated to the individuals to complete the module was sufficient and appropriate. 80%
4 The emotional competence of the adolescent was enhanced after the completion of the module. 88%
5 This module is capable of enhancing the emotion competence. 88%
Total Content Validity 85.6%
Inter-rater reliability (α = 0.606)
Based on Table 2, a high validity of 85.6% for Findings provide evidence that the Emotional
the overall module was calculated. Hence, it can be Competency Module is suitable to be implemented for
concluded thus far in the research that the module adolescents to help enhance their emotional competence
developed is appropriate to be implemented to enhance level. This is also similar to the Emotional Intelligence
adolescents’ emotional competence. Module (EeiM) which also revealed good content
validity[23]. Future suggestions for the research would
According to inter-rater reliability the α = 0.606, include that testing the module on a wider scale whereby
indicate that there was fair agreement among the rater adolescents’ population from different background
analysis on the module contents. such as juvenile delinquency center, international
secondary schools and private institutions can become
Discussions, Implications And Suggestions the participants. Besides, this module can certainly be
modified for use for differently abled adolescents.
The development of this module can aid the
Malaysian Youth Policy that helps prepare youths Conclusion
to lead the nation by empowering their emotional
competency skills. Besides, the module will also be a The Emotional Competency Module has a high
tool for psychologists or counsellors as well as other validity of 85.6% for the overall module which shows
that it is suitable to be used for the adolescent population
mental health professionals to implement this module
in Malaysia. Hence showing evidence that the Emotional
for adolescents identified with emotional competency
Competency Module can help enhance the emotional
issues. Numerous social problems happen today that
competence of adolescents.
start from less serious cases such as coming late to
school, skipping class, breaking rules, followed by Ethical Clearance: Ethical procedure and clearance was
serious cases such as disobeying teachers, smoking, carried from the Research Management and Invocation
participating in impulsive behaviors that has been Center of Sultan Idris University of Education.
reported by the mass media almost every day [20]. It is
Source of Funding: This research was supported
quite challenging to handle such numerous number of
by the Ministry of Higher Education through the
adolescent involving in problems in Malaysia. In Fundamental Research Grant Scheme (FRGS/1/2017/
accordance to this, many areas related to adolescent SS05/UPSI/02/6).
delinquency problems have been investigated by
researchers[21]. The Emotional Competency module is Conflict of Interest: There are no conflict of
developed to meet the challenge to work with vulnerable interest
youth to develop their emotional health. The four main identified thus far for this research.
emotional domains are used to assess the emotional
competency levels of adolescents in this study, and Acknowledgment
the valid and inter validity shown the higher (85%) of
This Research was supported by Ministry of
validity score. The contents of the module are valid with
Education (MOE) through Fundamental Research Grant
the inter reliability of experts (0.90). activities are most Scheme(FRGS/1/2017/SS05/UPSI/2/6) 02/5/2). We
useful and inspire way to practically build up the acknowledge the Ministry of Education and Research
emotional competency skills[22] Management and Innovation Center (RMICUPSI)
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DOI Number: 10.5958/0976-5506.2019.01672.3

Community Led Total Sanitation (CLTS) in Cikupa Village

and Teluknaga Village in Tangerang, Indonesia

Devi Angeliana Kusumaningtiar1, Gisely Vionalita1

1
Department of Public Health, Faculty of Health Sciences, Universitas Esa Unggul

ABSTRACT
Diarrhea incidence in Indonesia is 423 per 1000 population in 2006. Increased diarrhea cases in one area can
be controlled by sanitation approach. One of the Ministry of Health programs to improve Indonesian health
status is Community Led Total Sanitation (CLTS). Teluknaga and Cikupa Health Centers have differences
in the number of diarrhea cases. In addition and geographical conditions. This study used observational
quantitative study with cross sectional study design. In this study, there was no intervention. Study
sample consisted of
200 respondents (100 respondents in Cikupa village and 100 respondents in Teluknaga village). This study
used random sampling. One household will be chosen by one respondent to be interviewed. Analysis of the
data used independent t-test. The results showed that mean of CLTS for the Teluknaga village and
variable was -32.50 with standard deviation was 0.383. While, the mean of CLTS for Cikupa village was
44.14 with a standard deviation was 0.398. According to Mann Whitney test above showed that p-
value was 0.000
<α = 0.05. It meant that there was significantly different in CLTS between Cikupa and Teluknaga village,
Tangerang. Implementation of CLTS in urban and rural areas has been still different. However although
there were differences, it has been still a big and complex challenges. In addition, required varied methods,
tools and approaches. Latrine subsidy in households was long-term production by government support.

Keywords: Sanitation, Diarrhea, CLTS, Environmental,

Indonesia

Introduction endemic disease and also a potential outbreak

disease
Sanitation development challenges in Indonesia in Indonesia that often causes death. In 2015 there were
are community social culture and behavior. They are 18 outbreaks of diarrhea that spread in 11 provinces, 18
accustomed to defecating in any place, especially to districts/cities with a total sufferers was 1,213 people
water bodies which are also used for washing, bathing and 30 deaths (CFR 2.447%)(1). Based on cumulative
and drinking water. In addition poor hygiene and data from 43 Primary Health Care in Tangerang District,
sanitation have been still much. Study by The Indonesia 2014, it was found that the percentage of diarrhea cases
Sanitation Sector Development Program (ISSDP) in of all ages increased since 2011 to 2014. The highest
2006 showed that 47% of people behave defecation into cases of diarrhea in 2011 were 40.19%, in 2012 cases
rivers, fields, ponds, gardens and outdoors. increased to be 42.67%, in 2013 increased to 43.72%
WHO states that waterborne disease deaths cases and in 2014 also increased to be 51.34% cases(2).
reach
Increased diarrhea cases in one area can be
3,400,000 people per year, and diarrhea is the biggest
controlled by sanitation approach. One of the Ministry
cause of death, 1,400,000 people per year. The cause of
of Health programs to improve Indonesian health
death is poor sanitation and water quality. Diarrhea is an
status is Community Led Total Sanitation (CLTS).
CLTS is a government program to strengthen efforts to
Corresponding Author: accostume clean and healthy lives, prevent the spread
Devi Angeliana Kusumaningtiar of environment-based diseases, improve community
Department of Public Health, capacity, and implement government commitments to
Faculty of Health Sciences, Universitas Esa Unggul improve access of drinking water and basic sanitation
Email: [email protected] sustainably to achieve SDGs(3).
793 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 793

The CLTS National Strategy is a reference for on community led total sanitation that will cover five
planning, implementation, monitoring and evaluation pillars. Data analysis used an independent t-test analysis
related to CLTS. Health sanitation is closely related to to determine CLTS differences between Cikupa and
community culture. In an effort to foster community Teluknaga village.
participation must be considered also the community
socio-cultural conditions. To involve the community
Result
in development efforts, especially in the health sector
that will bring better results is if the process use Description of 5 pillars CLTS implementation in
educative approach that is trying to raise awareness Cikupa and Teluknaga Village as bellow:
in the community through increasing knowledge by
considering local social culture. Table 1: Description of CLTS in Cikupa dan
Teluknaga Village, Tanggerang (respondents)
Ministry of Health Indonesia stated that the lowest
percentage who implemented CLTS was DKI Jakarta Dwelling
Province 1.87% and Banten Province 24.44%, while CLTS
Cikupa Teluknaga
the highest percentage who implemented CLTS were Implementation
Good Poor Good Poor
Special Region of Yogyakarta Province 93.84%(4).
Open defecation free
50 50 9 91
Teluknaga and Cikupa Primary Health Care are (ODF)
located in Tangerang, Banten Province. Primary Health Hand washing with
79 21 24 76
Care Teluknaga is a primary health care that has an soap
ISO certificate and has been cases of diarrhea that fall Household drinking
into the top 10 diseases in the primary health care area, water and food 42 58 26 74
while the Cikupa is a primary health care that did not management
have an ISO certificate and for cases of diarrhea does Safekeeping of
not fall into the top 10 diseases. In addition, based 33 67 16 84
household waste
on geographical conditions, Cikupa Village is an Safekeeping of
administrative area, close to industries, factories, shops 7 93 3 97
household liquid waste
and roadside resident, the condition is crowded and
has sufficient facilities and infrastructure. Meanwhile, According to Tabel 1, the highest proportion of
Teluknaga Village has a population whose livelihoods handwashing with Soap in Cikupa Village was good.
are mostly fishermen, located on the coast, and the area While in the Teluknaga Village, the highest proportion
has many fish ponds. This differences is predicted due of household drinking water and food management
to the house and surrounding environment has not been properly was good.
health requirements, no sewerage, and littering behavior
and communities PHBS has been still lacking (2). Based Table 2: Description of Average CLTS in
on these problems, important to study about Community Cikupa dan Teluknaga Village, Tanggerang
Led Total Sanitation (CLTS) Differences between
Cikupa and Teluknaga, Tangerang District. Dwelling N Mean ± SD
STBM Teluknaga Village 100 32,50 ± 0,383
Methodology Cikupa Village 100 44,14 ± 0,398

This study was used observational quantitative Based on the table 2 showed that the mean of CLTS
study with cross sectional study design. In this study, for the Teluknaga village variable was -32.50 with a
there was no intervention. Study sample consisted standard deviation was 0.383. While, the mean of CLTS
of for Cikupa village was 44.14 with a standard deviation
200 respondents, 100 respondents in Cikupa village and was 0.398.
100 respondents in Teluknaga village. Sample collected
Furthermore, it was conducted normality test first
used random sampling. Each family head who was
for bivariate analysis. Results of the normality test
recorded at the household where the data was collected
showed that distribution was not normal with p-
will be chosen one respondent. The respondent criteria
value 0.000 <α
were sought as a family decision maker, a husband or
= 0.05. Then, non-parametric statistical tests were used
wife. Then, the respondent will be given a questionnaire
using Mann-Whitney U.
Table 3: CLTS Differences in Cikupa dan Teluknaga Village, Tanggerang
Dwelling N Mean p-value 95% CI
STBM Teluknaga Village 100
-11.640 0.000 -12.729 - -10.551
Cikupa Village 100
According to Mann Whitney test above showed was difficult to change, it seen from the community who
that p-value was 0.000 <α = 0.05. It means significantly already have latrines but still have defecation behavior
different of CLTS between Cikupa and Teluknaga in the river. This was in line with study stated that CLTS
Village. was an approach for long-term problems for a sustainable
national planning framework with the implementation of
Discussion CLTS promotion in schools, preparing cadres who follow
CLTS, the implementing CLTS’s cost included
Incident cases of diarrhea in Cikupa Village were facilitation and installation of latrines cost by own
lower than Teluknaga village. In Cikupa Village, resources, CLTS advocacy in churches and mosques,
diarrhea cases were not included in the top 10 diseases motivating children as a key role in using latrines in their
however in Teluknaga Village, cases of diarrhea had homes(9).
been still in the top 10 diseases. Then, study result
showed that there were differences in CLTS between Removing human waste (feces and urine) properly
Cikupa Village (low diarrhea cases) and Teluknaga and maintaining personal hygiene could maintain health.
village (high diarrhea cases). Study was conducted in If waste was not maintained and disposed incorrectly
Nyando in 2008, where diarrheal disease was found to and unsafe, it could be affected to human health and
be a major cause of morbidity and mortality among caused serious diseases such as diarrhea, dysentery,
children under five, especially in rural and suburban typhoid, cholera and other types of infectious diseases.
communities in the district. Thus, diarrhea contributes These health problems could be prevented if more effort
87% and 48% for child morbidity and mortality(5). was conducted for changes personal hygiene behaviors,
such as handwashing properly, waste disposed properly,
Requirement of sewage disposal that met to and using clean toilets with easy access to clean water
health rules were not polluting the soil surface, do not sources(10).
contaminate surface water, do not pollute soil water, dirt
could not be open so that it could be used as a vector Based on pillar 2 about handwashing with soap
for laying eggs and breeding . Factors that encourage
(6) showed that behavior of handwashing with soap in
indiscriminate disposal of fecal activities include Teluknaga village was lower than Cikupa village. Based
low socio-economic levels, insufficient knowledge in on the observations to the respondents who have lack
environmental health, and poor habits in disposal of behavior of handwashing with soap, they have only
feces that are passed down from generation to washing hands with water without soap and lacking of
generation. Build latrines depending on i) pre-existing respondent’s knowledge regarding to important times
social context factors, ii) socially intensive processes for washing hands. Washing hands with water was more
initiated by CLTS, iii) CLTS fosters the confidence to less effective in removing diseased germs from the hands
be able to build and rebuild toilets, and iv) CLTS than washing hands with soap. Hand washing using soap
communicates its benefits to health latrine(7). When the was one of the most effective and inexpensive ways to
community has succeeded in making changes and prevent diarrheal disease which mostly cau ses death in
declares its environment free of open defecation free children. Washing hands with soap after using the toilet
(ODF), the further challenge is to maintain these or helping children with bowel movements and before
conditions so as to ensure that no single member of the handling food could reduce the level of diarrhea, cholera
community returns to practice open defecation free and dysentery about 48 -59%(11).
(ODF)(8).
Household drinking water and food management
According to observations, there has been still many which was to be the pillar 3 of CLTS showed that the
respondents who behave less for pillars 1 to stop defecate proportion of poor behavior in Cikupa village was 58%
at any place. It was because the community behavior and the in Teluknaga village was 74%. Food must
be
managed well and properly in order to prevented health the government was also developing guidelines on
problems and benefit for body. A good way to manage how disposal activities should be carried out. This
food was by applying the principles of food hygiene and study stated that “Every liquid waste, especially from
sanitation. Household food management, although in hospitals, clinics, industries and any other hazardous
small scale or on a household scale must also applying liquid waste must be collected, cared for and changed in
the food principles of sanitation. A good hygiene a way that does not reduce the environment to prevent,
sanitation principles included sorted food ingredients, eliminate or reduce adverse effects on human health,
stored food ingredients, processed food, stored cooked resources nature, flora and fauna(13).
food, transported food, served food(3).
The traditional approach to rural sanitation is
Safekeeping of household waste which was to be based on two assumptions. The first assumption is that
pillar 4 of CLTS showed that the proportion of lack people do not know about sanitation and hygiene, but if
behavior in Cikupa village was 67% and in the they are educated they will change their behavior. The
Teluknaga village was 84%. Based on observations, it second assumption is that people will use the toilet if
showed that both of two villages there have not been they are given assistance to build it. However, these two
sorting organic and inorganic waste and did not assumptions are often proven wrong. Research shows
dispose of garbage every day. Still found trash around that knowledge of health risks associated with poor
the river and gardens proved that people’s awareness sanitation does not always trigger behavior change.
have been still lack for littering impact. Furthermore, the proportion of latrines built with
subsidies has never been used but as storage rooms,
Waste was a source of disease and a breeding
animal shelters. The traditional approach also focuses
for disease vectors such as flies, mosquitoes, rats,
on individual households rather than encouraging the
cockroaches. Garbage could be pollute the soil also
whole community to take collective action to clean the
and caused comfort and aesthetic disturbances such as
environment(14)(15)(16). Interventions focused on clean
unpleasant odors and unsightly views. Therefore waste
water, sanitation and hygiene have been shown to have
management was very important to prevent disease
an impact on the incidence of diarrhea from many
transmission. Trash must be available, trash must be
studies conducted(17).
collected every day and disposed of in temporary
shelters. If it was not reached by the service of garbage
disposal to the final shelter, it could be carried out by Conclusion
eliminating the waste by stockpiled or burned(12). Implementation of CLTS in urban and rural areas
has been still different. However although there
Household liquid waste management (pillar 5)
were differences, it has been still a big and complex
showed that the proportion was poor in the Cikupa
challenges. In addition, required varied methods, tools
village (93%) and Teluknaga village was 97%.
and approaches. Latrine subsidy in households was
Observations showed that in both village, it has been still
long-term production by government support. Thus, the
poor for safekeeping household liquid waste. It seen from problem of this study was people behavior who quite
inundated and uncovered drains in almost these villages. difficult to change in implementing CLTS.
Stagnant liquid waste could be a disease vectors source,
including public faucets or lavatories. Domestic liquid Competing Interst: This research is part of Ministry
waste must be disposed properly following to appropriate of Research Technology and Higher Education
standards of waste disposal. Domestic liquid waste (RISTEKDIKTI) Indonesian’s funding, thus, there is no
usually was not an extreme waste hazard to the competition in conducting this research.
environment except it was disposed incorrectly that could
Etchical Clearance: The study was approved by the
be impacted to surface water or shallow ground water. Ministry of Research Technology and Higher Education
The last and very important step in the waste (RISTEKDIKTI) Indonesian
management process was disposal that must be carried Source of Funding: This research is Ministry of
out in an eco-freindly. Rwanda city that liquid waste Research Technology and Higher Education
management was company’s responsibility, however (RISTEKDIKTI) Indonesian’s funding.
REFERENCES 10. Conant J. Sanitation and Cleanliness For a
1. Departement of Health Tangerang. Profile of Healthy Environment. Berkeley: Hesperian
Tangerang District Health Office; 2015 Foundation;
2005
2. Departement of Health Tangerang. Profile of
Tangerang District Health Office; 2014 11. United Nations Children’s Fund (UNICEF).
Handwashing; 2008
3. Ministry of Health. Indonesia Health Profile 2013.
12. Ministry of Health. Diarrhea Situation in
Jakarta; 2014
Indonesia. Jakarta; 2011
4. Ministry of Health. Guidelines for Implementing
13. Alice U, Ming Y, Nestor U and Narcisse N.
Community Based Total Sanitation. Jakarta; 2015
Liquid Wastes Treatment and Disposal in
5. Makotsi N, Kaseje D, Mumma J, Opiyo JLL. Rwanda. Journal of Pollution Effects & Control;
Association of Community Led Total Sanitation 2017
to Reduced Household Morbidity in Nyando
14. Curtis VA, Biran K, Deverell C. Hughes KB and
District. International Journal of Sciences: Basic
BD. ‘Hygiene in Thehome: Relating Bugs and
and Applied Research (JSBAR); 2016
Behaviour.’ Social Science and Medicine; 2003
6. Notoatmodjo S. Public Health Sciences Basic
15. Curtis VB, Kanki T, Mertens E, Traore I. Diallo
Principles. Jakarta: PT Rineka Cipta; 2003
FT and SC. ‘Potties, Pits and Pipes: Explaining
7. Harter M, Mosch, Sebastian and Mosler HJ. How Hygiene Behaviour in Burkina Faso.’ Social
Does Community Led Total Sanitation (CLTS) Science and Medicine; 1995
affect latrine ownership, A Quantitative Case Study
16. Scott BV, Curtis and T. Rabie. ‘Protecting
from Mozambique. BMC Public Health; 2018
Children From Diarrhea and Acute Respiratory
8. Kar K. Why not Basics for All? Scopes and Infections: The Role of Handwashing Promotion
Challenges of Community-led Total Sanitation. in Water and Sanitation Programmes.’ Regional
IDS Bulletin; 2012 Health Forum; 2003
9. Sah S and Negussie A. Community Led Total 17. Fewtrell L, Kaufmann RB, Kay D, Enanoria W,
Sanitation (CLTS): Addressing the Challenges Haller L, & Colford JMJ. Water, Sanitation, and
of Scale and Sustainability in Rural Africa. Hygiene Interventions to Reduce Diarrhoea in
Desalination; 2008 Less Developed Countries: a Systematic Review
and Meta-Analysis. The Lancet Infectious
Diseases; 2005
DOI Number: 10.5958/0976-5506.2019.01673.5

The Prevalence of Explained and Unexplained Subfertility—

A Case Study: Kirkuk City (Iraq)

Eman I Fathi
Department of Obstetrics and Gynecology, College of Medicine, University of Kirkuk, Kirkuk, Iraq

ABSTRACT
Infertility refers to the inability of a sexually active non-contracepting to get pregnancy in a one year. The
diagnosis of explained infertility is performed via standard fertility investigations, which encompasses:
assessment of ovulation, semen analysis and tubal patency test. The infertility is considered as an
unexplained when the standard fertility evaluation fails to identify an abnormality. This study aims to
determine the prevalence and main causes of subfertility. In this study, a multicentre survey is carried out at
the infertility centre at the Azadi teaching hospital in Kirkuk, Iraq during the period January 2016 –
October 2018. For this aim, 1023 patients are involved in this case-control study: where the females are
ranging in age from
18 to 45 years. The results show that (55.35%) have primary subfertility, whereas (44.5%) have secondary
subfertility. Additionally, (44.5%) and (75.65%) have primary and secondary subfertility respectively.
Furthermore, (75.65%) are explained while unexplained subfertility cases are found in (24.34%). The
main causes of female subfertility: 46.64% are ovulation disorders, (21.18%) are primary and (21.18%)
are secondary. Besides, out total (774 explained) patients, there is (15.24%) has tubal causes, (6.84%) are
primary and (8.39%) are secondary. Moreover, in (20%) the cause is due to male factor, (12.4%) are
primary and (7.62%) are secondary. Additionally, in (1.16%) of subfertility is caused by endometriosis,
(0.09%) and (0.03%) is primary and secondary subfertility respectively. (16.92%) have multiple disorders
found in both partners. Also, in explained subfertility in (63%), the females were responsible for the
subfertility, male factor alone is in (20%), (52.66%) are primary and (47.33%) are secondary. Finally,
regarding male factor subfertility, the outcomes shows follows: azoospermia in (7.1%), asthenozoospermia
in (21.93%), (55.48%) has oligospermia, (8.38%) has oligo-terato-asthenozoospermia and (7.1%) has
teratozoospermia.

Keywords: Infertility, azoospermia, oligospermia, asthenozoospermia, teratozoospermia

Introduction The World Health Organization (WHO) anticipated that

(60-80 million) couples around the world currently are
Subfertility is a worldwide concern can be either
subjected to have subfertility(2)(3). It varies across regions
primary or secondary. Primary subfertility is defined as
and expected to affect (8-12 %) of couples(4). It may also
inability to achieve pregnancy after one year of regular
be classified as explained in which there is one or more
intercourse while secondary subfertility is defined when
causes of subfertility and others are unexplained in
there is a preceding pregnancy irrespective to the
which all the basic investigations including tests for
outcome. It implies that the processes leading to
ovulation assessment, tubal patency,
conception have occurred successfully and so has a
hysterosalpingography, laparoscopy and seminal fluid
better prognosis(1).
analysis were normal . In the cases mentioned above,
(5)

abnormalities are likely to occur, however, it cannot

be identified by current methods. There are many
Corresponding Author: reasons which are as follows:
Dr. Eman I Fathi 1) the releasing of the eggs could not be at the optimum
Department of Obstetrics and Gynecology, period of fertilization which may not enter the fallopian
College of Medicine, University of Kirkuk, Kirkuk, Iraq tube. 2) the eggs can be reached by sperm which may
Phone: +964 (0) 7723147446 prevent fertilization. 3) Distribution of transporting of
Email: [email protected]
the zygote. 4) Fails in implantation(6). It is well
known
798 Indian Journal of Public Health Research
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Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 798

that the quality of the egg is crucial and the eggs of in the research, the female age was ranging
females in advanced maternal age have reduced capacity between
to achieve successful fertilization. Furthermore, in some
women with unexplained infertility, another reason
fertility complications could arise from polymorphisms
in folate pathway genes(4)(5). Therefore, unexplained
infertility is not the main reason. However, it is a
relative inability to get pregnancy, and lots of these
patients may be imagined without getting any
treatment(7).

It may be appropriate to investigate and treat those

patients with less than one-year history of subfertility
when they have obvious features which can lead to
subfertility such as patients with endocrine problems
like severe PCOS, hypothyroidisim or hyperthyroidisim,
female age more than 35 years or cases diagnosed as
endometriosis before marriage(8). There is some other
term in subfertility which is called fecundability which
means the probability of having a pregnancy within one
menstrual cycle(9). Female age and duration of
subfertility is the most important predictor of the
outcome. It is well known that the fecundity is reduced
with aging, it is usually decreasing in 32-years old, then,
it will fall dramatically in 37 (10)(11). In the other hand, the
rate of the natural monthly fecundity can be about (25%)
in ranging
20-30 years of age which reduces to under (10%) upper
the 35 years old. Furthermore, both the female and
male factor are involved and account approximately
for 35% (12). In over 5800 couples in 25 counties, WHO
identified that more than 85% of infertility among
African females was subjected to infection comparing
with 30% in females worldwide(13). This means that there
is the different demographic distribution of the causes
of subfertility. Accordingly, this work is also aiming
to investigate the existing surveys on the causes of the
prevalence of subfertility and proportion of couples in
order to obtain a medical help for fertility problems in
Kirkuk city in Iraq(14).

Patients and Method

To estimate the prevalence and main causes of

subfertility, a multicentre survey was conducted over 3
years and 9 months from (January 2015–October 2018)
in Kirkuk subfertility clinic of Azadi teaching
hospital.
1023 couples in this region, who consulted a practitioner
for primary or secondary subfertility during this period
were included in the study. patients who were involved
799 Indian Journal of Public Health Research
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 799
18-45, and male age was between 18-55 years, patient
with primary infertility had never get pregnancy, while
secondary subfertility include any patient had at least
one time in which pregnancy test was positive whatever
the outcome, whether it ended to full term pregnancy
or ended as early abortion, to all patients the main
basic investigation of subfertility were done including
hormonal profile (FSH, LH, TSH, Prolactin hormones
were estimated at the second day of the cycle, and
progesterone level was measured between day 21 -29
according to the patients cycle, all female patients had
test for tubal patency (HSG) which was done 2 days
after finishing her period, transvaginal ultrasound was
done on day 2 and day 13 to assess ovulation, and
seminal fluid analysis was done after 3 days of
abstinence.

Results

The study shown in the following tables. In Table

(1), it is shown that among 1023 patients, 567 patients
(55.35%) have primary subfertility among that primary
subfertility 311 (30.4%) of the patients were between
(18-30) years age, 198 (19.35%) their age was between
31-39 years, 58 (5.6%) were between 40-45. At the
same time from total cases (1023) it was found that
456 (44.5%) have secondary subfertility, 261 (25.5%)
their age was between (18-30), 163 (15.9%) their age
was between (31-39), 32 (3.1%) patients their age was
between (40-45). In Table 2 three fourth from the total
number of cases 774 (75.65%) were explained while
unexplained subfertility cases were found in one fourth
249(24.34%) of the couples surveyed. In Table (3)
result shows that the main causes of female subfertility
were ovulation disorders 361 (46.64%), 197 (25.46%)
were primary and 164 (21.18%) were secondary. Out
of 1023 total patients (774 explained) there was 118
(115.24%) had tubal causes, 53 (6.84%) were primary,
and 65 (8.39%) were secondary. In 155 (20%) the
cause of subfertility was only due to male factor 96
(12.4%) was primary and 59 (7.62%) were secondary. 9
(1.16%) patients had endometriosis, 7 patients (0.09%)
was primary and 2 (0.03%) secondary subfertility. 131
(16.92%) had multiple disorders in which the cause
was found in both partners. Out of 774 cases (explained
subfertility), the females were responsible for subfertility
in 488 (63%) which means that more than half of the
cases of explained subfertility were only due to female
causes, and male factor alone was in 155 (20%), which
mean around one-fifth of explained subfertility was
due to male factor alone. 257 (52.66%) were primary, 11 (7.1%), 34 (21.93%) patients the cause of male factor
and 231 (47.33%) were secondary as shown in Table 3. was asthenozoospermia, 86 (55.48%) oligospermia,
Regarding male factor subfertility, out of 155 patients 13 (8.38%) had oligo-terato-asthenozoospermia, and
with male factor subfertility, azoospermia was found in teratozoospermia in 11 (7.1%) patients.

Table 1: Distribution of primary and secondary subfertility according to female age

Types of subfertility
Age groups No of patients Primary Secondary
No. % No. %
18-30 572 311 30.4 261 25.5
31-39 361 198 19.35 163 15.9
40-45 90 58 5.6 32 3.1
Total 1023 567 55.35 456 44.5

Table 2: Number of explained and unexplained subfertility

Causes of subfertility
Explained Unexplained
No. % No. %
Primary (567) 429 41.93 138 13.48
Secondary (456) 345 33.72 111 10.85
Total 1023 774 75.65 249 24.34

Table 3: Causes of Explained subfertility in 774 male and female patients

Causes
Endometriosis Anovulation Tubal factor Male factor Combined
No. % No. % No. % No. % No. %
Primary (411) 7 0.09 197 25.46 53 6.84 96 12.4 58 7.4
Secondary (363) 2 0.03 164 21.18 65 8.39 59 7.62 73 9.43
Total 774 9 1.16 361 46.64 118 15.24 155 20 131 16.92
488 (63%) total only female causes alone 155 (20%) 131 (16.92%)

Table 4: Types of abnormalities in the seminal fluid analysis of 155 patients with male factor subfertility

Abnormalities in the seminal fluid analysis

Asthenozospermia

Teratozospermia
oligoasthenozo-
oligospermia
Azospermia

ospermia

No. % No. % No. % No. % No. %

Primary 94 (60.64%) 11 7.1 21 13.54 47 30.32 8 4.68 7 4.51
Secondary 61 (39.35%) 0 0 13 8.38 39 25.16 5 3.22 4 2.58
Total 155 11 7.1 34 21.93 86 55.48 13 8.38 11 7.1
Discussion low level of sexual transmitted disease in Iraq is because
of the country religion is Islam which prohibits the sexual
WHO has reported in(1), in developing countries,
relations between the unmarried couples.
25% of couples are found to be infertile. Additionally,
the organization stated that the prevalence of females In Sub-Saharan Africa(16), primary infertility is
has kept as it is from 1990 to 2*010. In 2010, US CDC less common than secondary infertility, where most
reported that the prevalence rate of infertility was 10.9% often the outcome of untreated STIs or complications
where the rate has demonstrated variations across parts from pregnancy/birth(14). Since the 1980s, there was
of any country(2). It is worth mentioning that an increasing in infertility rates about 4%, and most of
abnormalities are possible to present; however, they can them are due aging(15). It is well known that the females
not be detected via current methods. In this study, we become less fertile as they grow old. For instance,
found that the prevalence of unexplained subfertility females in 35 years old get pregnant after three years of
reached 24.34% similar to US prevalence rate (the regular unprotected intercourse. Nevertheless, only 77%
unexplained infertility rate was about 25% of infertile women in 38 years old get pregnant after three years
couples)(8). Furthermore, we found that the rate of male of regular intercourse. In the UK, in infertile couples,
subfertility is 23.25%. This rate is less than what has male factor infertility rate reaches 25%, and another
obtained in India where the malefactor prevalence was 25% remains as unexplained infertility (17). On the other
between (40- 50%) and impacts of 7% of all males(12). hand, 10% of couples in Sweden who seek for children
are infertile(18). Additionally, male factor, female factor,
The incidence of pathological subfertility is difficult and both side factors have equally rate (about 33%) of
to determine precisely, especially for male factor infertility in all these cases(18).
due to our social culture which always defends men
against women resulting in delay or underestimating
Conclusion
the diagnosis of the male element. In some cultures,
subfertility bears a sense or stigma of being declined We concluded that there are differences in the
by the couple. Additionally, therefore, subfertility causes of the subfertility in different areas in the world.
causes a noticeable disillusionment(15). It is well known Several reasons are behind this finding which can be as
that the subfertility reasons vary with geographic and follows:
socioeconomic variation(11). Deprivation, starvation
and mass migration due to war in Iraq, especially in Religious points.
Kirkuk city in the last 4 years. Furthermore, the high The age of marriage.
cost of infertility investigation and treatment and non-
availability of them in government hospital make Poverty.
patients unable to attend private infertility clinic. On
The differences in the national resources in each
limit resources, the infertility places a large burden by
country which can support subfertile people.
seeking helps for widespread couples.
Conflict of Interest: The authors have no financial,
The results demonstrated that 63% from total
consultative, institutional, and other relationships that
774 patient with explained subfertility was due to
pure might lead to bias or conflict of interest.
female causes. Also, 46.64% have anovulation Source of Funding: The authors have no sources
and of
15% tubal causes. This finding is similar to study done funding, so it is self-funding research.
in England where it was found that 50% are female
causes, 25% is due to anovulation and 25% are caused Ethical Clearance: We declare that the study does
by tubal problems. In the literature, the studies showed not
that the woman causes are ranged between 25-37% of the need ethical approval.
infertility worldwide. The larger proportions in Southeast
Asia and Sub-Saharan Africa are mainly caused by tubal REFERENCES
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childlessness in developing countries. 2004; assisted conception in perspective. Fertil Steril.
3. Organization WH, Organization WH. Infecundity, 1995;64(2):252–4.
infertility, and childlessness in developing 12. Kumar N, Singh AK. Trends of male factor
countries. DHS Comp reports. 2004;9. infertility, an important cause of infertility:
4. Shankardass MK. Looking back, looking forward: A review of literature. J Hum Reprod Sci.
A profile of sexual and reproductive health in 2015;8(4):191.
India. JSTOR; 2006. p. 338–40. 13. Ombelet W, Cooke I, Dyer S, Serour G, Devroey
5. Moghissi KS, Wallach EE. Unexplained P. Infertility and the provision of infertility
infertility. Fertil Steril. 1983;39(1):5–21. medical services in developing countries. Hum
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6. Aston KI, Uren PJ, Jenkins TG, Horsager A,
Cairns BR, Smith AD, et al. Aberrant sperm DNA 14. Killick S, Trussell J, Cleland K, Moreau C.
methylation predicts male fertility status and Factors associated with subfertility among women
embryo quality. Fertil Steril. 2015;104(6):1388–97. attending an antenatal clinic in Hull. Hum Fertil.
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7. Altmäe S, Stavreus-Evers A, Ruiz JR, Laanpere
M, Syvänen T, Yngve A, et al. Variations in folate 15. Schmidt L, Christensen U, Holstein BE. The
pathway genes are associated with unexplained social epidemiology of coping with infertility.
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8. Isaksson R, Tiitinen A. Present concept of 16. Gerais AS, Rushwan H. Infertility in Africa.
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DOI Number: 10.5958/0976-5506.2019.01674.7

Cellular Immunity of River Water Consuments and

Bandarmasih Municipal Waterworks Consuments
Huldani1, Bayu Indra Sukmana2, Rahmiati3, Anindya Pujiningtyas4, Eldha Savitri4, Fauziah4, Ummi
Nihayah4
1
Department of Immunology and Physiology, Medical Faculty, 2Departement of Oral Radiology,
Dentistry
Faculty, 3Departmentof Microbiology, 4Medical Students, Medical Faculty, Lambung Mangkurat
University

ABSTRACT
The quality of water used for daily needs affects human health. Some people in Banjarmasin use the PDAM
Bandarmasih water and some use Martapura River water. One of the infection signs is the increases of white
blood cell, includes neutrophil, monocyte, eosinophil and lymphocyte. The aims of this study was determine
the differences of neutrophil, monocyte, eosinophil and lymphocyte count between Martapura river water
consuments and Bandarmasih Local Water Supply Utility consuments in Banjarmasin. This study was an
analytic observational with a cross sectional approach. Sample selection used purposive sampling technique.
The result showed that neutrophil, monocyte, eosinophil and lymphocyte count average level of 30 consuments
of Martapura River water were 54.03%, 7.43℅, 3.2℅, 34.8%, respectively; and neutrophil, monocyte,
eosinophil and lymphocyte count average level of 30 consuments of Bandarmasih Local Water Supply Utility
was 54.9%, 7.53℅, 4.39℅,
32.8%, respectively. Statistical analysis with unpaired t-test showed that there wasn’t any difference of
neutrophil, monocyte, eosinophil and lymphocyte.count between Martapura River water consuments and
Bandarmasih Local Water Supply Utility consuments (p=0.723, p=0.822, p=0.623℅, p=0.318) in August 2018
period.

Keywords: river water consuments, local water supply consuments, immunity, leukocytes
Introduction possible to find many bacteria, viruses, and parasites in
polluted water.3The bacteriological test of river water in
The river flow in the Province of South Kalimantan,
Berangas, Barito Kuala showed that the MPN values of
especially the City of Banjarmasin, is used for various
Coliform and E. Coli are respectively 29 and 0 MPN/100
activities. The percentage of river water use by the
ml. The MPN value of Coliformdropped to 18 MPN/100
people of the Alalak River to clean their houses is 95%;
ml in the river water which has been given alum.
to water the plants 92%; to bath 77%; to wash the
clothes, the cooking utensils, and the eating utensils Another cause of river water pollution in the city
74%; and forthe ablution 1%.1 of Banjarmasin is the disposal of domestic waste and
factory waste into the river.4 As the population increases,
The more the activity of the people on the riverside
grows, the higher the level of pollution in the waterdue the effortsto fulfill the water needs are increased through
to the direct household waste thrown away to the the Local Water Company (PDAM). The clean water
water.2The huge amount of waste disposalinto the river in the city of Banjarmasin is supplied by the PDAM
will make the quality of water worse.As many as 34% of Bandarmasih through the process of coagulation-
the people around the river in Banjarmasin throw feces flocculation, filtration, sedimentation and disinfectation.
directly into the river and 64% use traditional septic tang Chlorineisa disinfectant commonly used by PDAM. This
5

(cubluk) that do not meet the requirements of good substance is capable of killing pathogenic bacteria
sanitation, causing the surrounding environment to be and protozoa in the water and inhibiting the growth
polluted. It is very of
moss.6The existence offreechlorine compound in the
Corresponding Author: Phone: +6285242739400
Harun Achmad Email: [email protected]
Pediatric Dentistry Department, Faculty of Dentistry,
Hasanuddin University, Makassar,
South Sulawesi, Indonesia
distribution of water permitted by PERMENKES
2010is
0.2-0.5 mg/l.7

The microbiological quality of water provided

by PDAM Bandarmasih is proven to be good
through the analysis of the quality of customers clean
water of Water Treatment Plant (IPA)zone 1
PDAM Bandarmasih on
803 Indian Journal of Public Health Research
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 803

the period of June-July 2018, the amount of E. Coli and Table 1: Characteristics of Respondents of Water
the total of Coli is 0 per 100 ml of water in the sample Users of Riveron Ray Street 17 and Water Usersof
thatmeets the drinking water requirements.8 PDAMon Maluku Street inAugust 2018 according to
Gender, Range of Age, Current Disease History
Neutrophils together with monocytes are phagocytic
(RPS), Drug Consumption History and Neutrophil
cells and are the first immune cells to respond during
Levels
infection to fight bacteria.9 Eosinophils play a role in Group
allergic and parasitic infections.10 Whereas lymphocytes
Water User Water User
are able to produce the body’s defense components of River of PDAM
against foreign objects that have been specifically

Percentage
Category

Total

Total
Percentage
identified. There are B lymphocytes that function in
humoral immunity and produce antibodies in the blood,

(people)

(people)
and T lymphocytes as cellular immunity that does not
produce antibodies, but works directly to destroy specific

(%)
(%)
foreign objects with chemicals.9,10 1 Gender
The poor water quality, especially microscopically, Female 19 63.3 23 76.7
increases the risk of infection for its users, one of which Male 11 36.7 7 23.3
is an increase in the number of leukocytes. Based on the
description above, a study was conducted to determine 2 Range of Age (year)
the differences in the number of neutrophils, monocytes, 18-31 5 16.7 3 10
lymphocytes and eosinophils of Martapura River water
32-46 13 43.3 18 60
users with water users of PDAM Bandarmasih.
47-60 12 40 9 30
Research Materials and Method 3 Current Disease History (RPS)
Pain 2 6.66 2 6.66
The implementation of this study was using an
observational analytic cross sectional method. The Hypertension 0 0 1 3.33
population of this study is the people using the water Hypercholesterol 0 0 1 3.33
from Martapura River on Ray Street 17 RT. 02 Berangas
Anemia 0 0 1 3.33
District with a total population of 155 people and the
people using the water from PDAM Bandarmasih on Diabetes mellitus 0 0 2 6.66
Maluku Street RT. 05 Pasar Lama District with a total 4 Drug Consumption History
population of 176 people for daily needs in Banjarmasin
Antihipertensi 4 13.33 1 3.33
City in August 2018.
NSAID 2 6.66 2 6.66
Results Anticholesterol
0 0 4 13.33
(statins)
The Shapiro-Wilk test showed that the data on the
number of neutrophils and lymphocytes of river water Contraception (birth
2 6.66 2 6.66
control pill)
user group and PDAM water user group spread out
normally. The data onthe number of eosinophils and Antipyretic 1 3.33 1 3.33
monocytes were not normally distributed, hence data Ulcer medication
transformation was carried out. After all data were (antacid & H2- 2 6.66 3 10
normally distributed, it was followedby hypothesis receptor antagonist)
testing with unpaired t, the results showed that there
Chlorpheniramine
were no statistically significant differences in the number 1 3.33 1 3.33
maleate
of neutrophils, monocytes, lymphocytes and eosinophils
between the two groups of research subjects with p Anti gout 0 0 1 3.33
values of 0.723, 0.822, 0.623 and 0.318. Antihyperglycemic 0 0 2 6.66
Table 2: Results of Laboratory Test of Water from PDAM Bandarmasih on Maluku Street, RT 05,
Banjarmasin and Water from Martapura River on Ray Street 17, RT 02, Berangas with and without
Alum

Parameter Maximum Limit River Water River Water with Alum PDAM Water
1. Physics
Color ≤15 19.7 2 5
Turbidity(NTU) ≤5 84.6 0.1 1.27
Temperature (Co) Air temperature ± 3 26.9 26.9 26.5
2. Chemicals
Chlorine(mg/L) ≥0.2 - - 0.82
Aluminium (mg/L) 6.5-8.5 0.55 1.25 -
Iron (mg/L) 1.0 2.24 0.09 -
Lead (mg/L) 0.2 0.38 0.1 -
3. Bacteriological
E. Coli (MPN/100 mL) 0 0 0 0
MPN Coli (MPN/100 ml) 0 50 18 0
Table 3: Average Number of Neutrophils, Discussion
Monocytes, Lymphocytes and Eosinophils in
Respondents ofWater Users of Riveron Ray The average number of each cell type is almost
Street 17, RT 02, Berangas and Water Users of entirely within the normal range, both in the group
PDAM Bandarmasih on Maluku Street, RT 05, of the river water users and thegroups of the PDAM
Banjarmasin in the Period of August 2018 water users.Only the average number of eosinophils of
PDAM water users has increased from the normal value
Group of User Respondent (4.39%). The statistical results showed that there
Martapura PDAM were
no significant differences in the number of
# Category
River Water Water neutrophils,
N % N % monocytes,
two groups lymphocytes andthis
of respondents, eosinophils
could bebetween
due to the
1. Monocytes two groups of respondents giving direct treatment of
Average 30 7,43 30 7,54 water to be used, namely deposition, alum and
Normal 20 6,36 18 6,28 boiling
which could interfere with the sustainability of the
Monocytosis 10 9,57 12 9,4 pathogenic bacteria in the water thereby reducing
Monocytopenia - - - - the of infection for users. In addition, the use of
risk
2. Neutrophils soap,
toothpaste and other cleaning agents can kill pathogenic
Average 30 54,03 30 54,9 microorganisms because they are antibacterial.
Normal 19 57,2 18 59,25
The river water used by the people on Ray
Neutropenia
Street 9 42.3 11 46.2

needs is always accommodated and given the alum

3. Eosinophils
which functions as a floculator where its activities
Average 30 3,21 30 4,39
are to agglomerate pollutants such as industrial residues,
Normal 14 2,8 9 3
metals, and microorganisms and are known also as
Eosinopenia 9 1 9 1,2
an antibacterial .Alum can inhibit the bacterial growth. The
Eosinophilia 7 7 12 7,9 11
concentration of alum as much as 1% makes gram-
4. Lymphocytes positive
bacteria experience a death phase, and the concentration
Average 30 34,8 30 32,8
of 2% causes the death of gram-negative bacteria.
Normal 19 31,4 21 31
Lymphocytosis 9 46 5 42,5 The disposal of soap and detergent waste into
Lymphocytopenia 2 17,5 4 22,7
the river results to aworse quality of river water.
However,
alum can reduce detergent levels by absorbing dyes and under 15 years old.And there is no significant difference
other pollutants, and alum is effective in reducing iron between antibacterial soap and ordinary soap in its
levels in water.13 effectiveness in killing bacteria.22
Particularly for drinking water, besides being given Although there were no statistically significant
alum, it can also be boiled. The bacteria and the other differences between the neutrophil counts of the two
pathogens in the water that go through a cooking process groups of respondents, there were variations in the
to 100°C for 5-10 minutes will disappear.14
number of respondents between the two groups of
The water needs for the daily activities of people in respondents. This was probably due to the differences
Maluku Street, Pasar Lama are fulfilled with the water in the environmental characteristics of the two research
from PDAM Bandarmasih. The water has been given locations. Maluku Street is a market area with dense
chlorine as a disinfectant. The results of qualitytest environmental characteristics. The houses and the
of PDAM water (table 2)are in accordance with the merchant stalls are located side by side on both sides
standard, where one of the indicators, known as the of the road with a large number of local people and
value of water turbidity, is not more than 5 NTU. It is market visitors.An environment with a huge amount of
because the high value ofturbiditywill reduce the population and a minimum amount of air ventilation can
disinfection activity during the processing of water increase the density of germs or bacteria.23 The people
purification.15 around such location have a higher risk of exposure
The disinfection will work effectively if the free chlorine
to bacteria. Meanwhile, on Ray Street 17, Berangas
in the water amounts to between 0.2-0.5mg/l, if the
District, it looks cleaner.
disinfectation is less, it will not be effective, andif it is
more, it will be carcinogenic.16 Gender also affects the number of leukocytes. In
this study, the number of female respondents in the
The disinfection process of water from PDAM
Bandarmasihis proven to be good, according to the lab group of river water users (19 people) was less than the
results in June 2018 showing that the MPN values of female respondents in the group of PDAM water users
Coliform and E. Coliare 0 per 100 mL.17 Therefore, (23 people). The immune response of women is faster
the water flow that reaches the people’s houses is of to respond toinfectioncompared to the immune response
good quality and free of pathogenic microorganisms. of men. When an infection occurs, a woman’s immune
This is in accordance with the results of the study that system recognizes and destroys pathogens that enter the
the average number of neutrophils, monocytes and body more quickly than men.24
lymphocytes using PDAM water on Maluku Street,
RT02, Banjarmasin is in the normal range. Conclusion
In addition to the direct treatment of water used, Based on a study of the difference in the number
people in both locations also use soap for bathing,
of leukocytes ofusers of water from Martapura Riverand
washing dishes and other eating utensils, and toothpaste
users of water from PDAM Bandarmasih, it was
for brushing their teeth. One of the ingredients contained
concluded that the average numbers of neutrophils and
in toothpaste is flour which is antibacterial. The use of
toothpaste with flour has been proven to be effective in monocytes, lymphocytes and eosinophils of the people
killing bacterial colonies.18,19 The antibacterial content using the water from Martapura River in August 2018
found in toothpaste is baking soda (sodium bicarbonate). were 54.03%, 7.43%, 34.8% and 3.2%. The average
Baking soda is alkaline which can neutralize the pH of numbers of neutrophils, monocytes, lymphocytes and
the oral cavity, so that it can inhibit the bacterial eosinophils of the people using the water from PDAM
metabolic activity. Baking soda also has hypertonic were 54.9%, 7.54%, 32.8% and 4.39%, respectively.
activity which later results in hypotonic content of The statistical results showed no significant differences
water-losing bacteria which will make the bakery cells between the average number of neutrophils, monocytes,
become dehydrated and can eventually destroy the lymphocytes and eosinophils ofthe water usersof
bacteria.20,21 Martapura Riverand the water users of PDAM
Bandarmasih.
Ordinary soap (not antibacterial) can reduce 50% of
pneumonia in infants and 53% of diarrhea in
children
Source of Funding: Domestic government 9. Sherwood, L. Human physiology:from cell to
system. 8th ed.EGC, Jakarta. 2014.
Conflict of Interest: There is no conflict of interest
in 10. Guyton, A.C, Hall, J.E.Medical physiology
this study. textbook.12thed.Elsevier, Indonesia.2014.

Ethical Clearance: This study obtained a label of ethics 11. Susanto. Effect of demographic characteristics,
escaped by the number:761/KEPK-FKUNLAM/EC/ utilization of river water and chemical parameters
VIII/2018 on August 10, 2018 of water on dermatitis in the community using
river water in Gampong Teungoh in 2016
[Thesis]. University of North Sumatra, Medan.
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Education. 2016;3:33–41 13. Tamzil A., Dwi Y., dan Lola R. Effect of addition
2. Hapsari D, Sari P, Pradono J. 2009. Effect of of alum AI (SO ) and chlorine Ca(OCI) on
the 2 4 3 2
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14. Ananda PR, Ismail A. Effect of 30-day dose of
3. Rahman A, Alim MS, Utami UB. Inventory alum in feed for 30 days on liver histopathology
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from institutional sources in Banjarmasin City.
PDAM Tirtanadi Water Treatment Plant (IPA)
Biodidaktika. 2015;10(2):1
Silver Overlay [Thesis]. Universitas Sumatera
5. Sofia E, Riduan R. Evaluation of the presence of Utara, Medan. 2017.
free chlorine in the Sungai Lulut IPA distribution
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6. Cahyaning, N. dan Mulyadi, A. Effect of Siak PDAM. Support the Journal of Environmental
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Pekanbaru). Journal of Environmental
Sciences. 18. Pratama, R.N. The antibacterial effect of
2009;3(1):46-57. toothpaste containing baking soda and toothpaste
containing flour against the growth of plaque
7. Pemerintah Indonesia. Health Minister Regulation
bacteria [thesis]. Faculty of Dentistry, Hasanuddin
of the Republic of Indonesia No.492/Menkes/
University, Makassar. 2014.
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requirements. Republic of Indonesia Gazette. 19. Mardiana Adam, Achmad H. The Relationship
Jakarta: Sekretariat Negara. 2010. of Mineral Fluor Exposure in Water with The
Presence of Gingivitis(Study Case in Subdistrict
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Brasileiraem Odontopediatria e Clinica Integrada
2019;19(1):e4325
DOI Number: 10.5958/0976-5506.2019.01675.9

Role of Sentinel Lymph Node Biopsy in Staging of Early

Endometrial Cancer

Mohamed Soliman Elmahdy1, Gamal Abdelhalim Amira1, Mohamed Abdelfatah ElZohairy1, Abdelhamid
Mohamed ElKalawy1, Zeiad Samir Gad1, Eman Naguib Khorshed2
Surgical Oncology Department, 2Pathology Department, National Cancer Institute, Cairo University,
1

Egypt

ABSTRACT
Background: Many endometrial cancer patients will undergo a comprehensive lymphadenectomy despite
having disease confined to the uterus with low percent of lymph node metastasis, resulting in prolonged
operating time, additional cost, and potential side effects, sentinel lymph node (SLN) procedure has been
evaluated in Endometrial Cancer and has emerged as a possible middle solution to overcome under
treatment of high risk patients or over treatment of low risk patients.
Method: This is a cross sectional non randomized, prospective study, non-comparative study with the
purpose of determining rate of SLN detection at Egyptian National Cancer Institute, Cairo University for
patients presented with early endometrial carcinoma.
Results: 46 patients have SLN using blue dye. 32 case injected with methylene blue (69.6%) and patent
blue injection was in 14 cases with (30.4%). SLN was detected in 39/46 cases with detection rate (84.8%).
With failure of detection in 7/46 cases with failure rate (15.2%), false -ve rate 16.7% and test sensitivity is
84.3% with NPV 97.1% and accuracy 97.4%. No false positive cases present in this study this means that
False +ve rate 0%, specificity 100% and PPV 100%.
Conclusion: SLN using Blue dye is very simple especially in low resource countries but is associated with
low detection rate and false negative rate. As surgeons gain experience in SLN mapping for endometrial
cancer and achieve detection rates of 90% or greater, with a combined decrease in false-negative rates.

Keywords: blue, dye, endometrial, lymphadenectomy, lymphedema

Introduction and paraortic nodes. Also parametrium and presacral

areas are at risk. This pattern of spread needs complete
Endometrial cancer is the most common malignancy
staging with pelvic and paraortic lymphadenectomy.2
of the female reproductive tract worldwide, in Cairo
National Cancer Institute registry, it is the third most Histological grade, depth of myometrial invasion,
common gynecological cancer constituting 23%, with lymph node metastasis are the most important
median age is 60 years. 1 prognostic factors of endometrial cancer. 3 Thus FIGO
group recommends pelvic lymphadenectomy to stage
The uterus is midline structure, its lymphatic
patient disease and assess lymph node status, whereas
drainage
GOG group recommends systematic pelvic and paraortic
likely to be bilateral mainly along obturator, iliac, caval
lymphadenectomy which is associated more morbidity. 4

Surgical staging by total abdominal hysterectomy,

Corresponding Author: bilateral salpingo-oophorectomy and pelvic
Mohamed Soliman Elmahdy, MD, EBSO lymphadenectomy was agreed by most surgeons
Surgical Oncology Department, as standard of care for patients with grade 2 and 3
National Cancer Institute, Cairo University, Egypt endometrioid cancer as well as patients with clear cell
Phone: +201001096817 and papillary serous tumors. 4, 5
Email: [email protected]
809 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 809

Patients with grade 1 endometrioid cancer some for surgery till 10 minutes after fundal injection and
of them are staged appropriately others are not staged about
according to surgeon assessment during surgery. This 25 minutes after cervical injection, it was estimated that it
increased concern about over treating low risk group of might take up to 30 minute for tissues to absorb blue dye
patients who may have prolonged survival especially and to be taken by lymphatic vessels to turn lymph node
when complete regional lymphadenectomy is done blue. Surgery was proceeded as routine and started with
which may have long term effects and morbidity. 6, 7 pelvic lymphadenectomy for which visual identification
of colored or blue nodes were searched for and identified,
Sentinel lymp f symptomatic lymphedema, bleeding, its anatomical site was reported, and such node excised
increase operative time and cost. 8 separately and sent separately for histopathological
Aim of the Work: To detect the accuracy and examination, then surgery was completed as standard
sensitivity of colorimetric method of SLN in staging of (total abdominal hysterectomy, bilateral
endometrial cancer, to evaluate the feasibility of SLN to salpingooophorectomy and standard pelvic
stage patients with early endometrial cancers. lymphadenectomy). None identified SLN or failed
mapping was reported, and surgery also completed as
standard.
Patients and Method

This cross-sectional study was conducted on Results

endometrial cancer patients presented to National
Cancer Institute, Cairo University, Egypt 46 patients with endometrial carcinoma meeting
selection criteria underwent SLN procedure in
Inclusion Criteria: Stage IA histological grade 2 and 3 endometrial carcinoma using colorimetric method using
endometrioid adenocarcinoma, clear cell and papillary either methylene blue (69.6%, n=32/46) or patent blue
serous carcinoma, Stage IB endometrial carcinoma, (30.4%, n=14/46) cervical (34.8%, n=16/46, injection
Stage II endometrial carcinoma. site 3 o’clock and 9 o’clock superficial and deep) and
or cervical and fundal subserosal injection (65.2%,
Exclusion Criteria: Patients with grade 1 endometrioid n=30/46). Their mean age was 57.9 years with range
adenocarcinoma, stage III and IV disease, and patients (51-69). All patients (100%) have been surgically done
with allergy to blue dye. through laparotomy and all have preoperative pathology
endometrial carcinoma. 67.4% (n=31/46) of patients had
Study Design: This non-randomized, prospective, non-
less than myometrial invasion and 32.6% (n=13/46) had
comparative study for determining the SLN detection
more than half myometrial invasion. Mean time to detect
rate by histopathological examination, anatomical
SLN defined as time from dye injection till visualization
distribution of SLNs.
of dye colored node (SLN) was 30 minutes with range
Method used for SLN in Endometrial Cancer Cases: (20–40) minutes. The detection rate was calculated as
Cervical injection of blue dye 2-sided at 3 and 9 o’clock, the number of patients with at least one detected pelvic
4 ml used in a combined superficial (1-3 mm) and deep colored SLN divided by the total number of patients
(1-2 cm) cervical injection, fundal injection with 2 ml who underwent SLN mapping. SLN was detected in
of blue dye has been also used in number of cases with 84.8% (n=39/46) of cases. Location of detected colored
cervical injection. SLN included obturator group (59%, n=23), internal
iliac group (23.1%, n=9), paracervical (15.4%, n=6) and
Procedure: After anesthesia patient cervix was and external iliac group (2.6%, n=1), bilateral detection was
22-gauge spinal needle was used to inject blue dye into reported in 33.3% (n=13).
cervix at 3’oclock and 9’oclock for each side 2ml of
All SLNs were examined histopathologically and
dye (1 ml superficial from 1-3mm depth and the other 1
the uterus examined for myometrial invasion, grade of
ml deep 1-2cm cervical depth). Immediately following
carcinoma, LVSI and pelvic lymphadenectomy
cervical injection surgical field prepared, abdomen was
examined histopathologically for lymph node metastasis.
opened and 2ml of blue dye was injected subserosal in
uterine fundus, field prepared and abdomen was Pathological nodal metastasis had been detected
packed in 12.8% (n=5/39) of examined SLNs, and in
15.2% (n=7/46) of standard postoperative pelvic
lymphadenectomy. Postoperative less than half series of 15 patients they occluded the tubes with
myometrial invasion was detected in 67.4% (n=31/46) clips and injected isosulfan blue into the subserosal
patients while 32.6% (n=15/46) patients had more
than half myometrial invasion. Pathological grading of
endometrial carcinoma showed 11 case (23.9%) as G I,
33 case (71.7%) as G II and 2 cases (4.3%) as G III.

Diagnostic Accuracy of SLN: One case of detected

SLNs have negative histopathological examination and
their associated standard pelvic lymphadenectomy was
proved to be positive for nodal metastasis which means
that false -ve rate was 16.7% and test sensitivity
was
84.3% with NPV 97.1% and accuracy 97.4%. No false
positive cases were detected in this study meaning that
False +ve rate was 0% with specificity 100% and
PPV
100%. Significant higher LN positivity with myometrial
invasion more than half ‘6/9’ than those with less than
half myometrial invasion ‘1/30’ was detected (40%
vs.
3.25; P=0.003). LN positivity in grade II and III (20%)
versus no positive LN with grade I (0%) has been found
(P=0.107). Out of 7 cases with undetected SLN, one
case proved to have +ve nodal involvement on
pathological diagnosis which means failure rate of
14.3%.

Discussion

LN metastasis affects management of

endometrial
cancer and usually indicates a poor prognosis. 9, 10
Thus, surgical staging with pelvic LN dissection is
recommended for all high-risk endometrial cancer
patients. However, most patients with endometrial
cancer don’t not have LN metastasis making
lymphadenectomy and its drawbacks major concern,
many surgeons perform selective lymphadenectomy
based on pre or intraoperative findings. As the
decision to perform LN staging often is based on the
individual surgeon’s experience there is a lot of bias.

The challenge is to identify accurate surgical

technique to stage endometrial cancer and avoid
unnecessary morbidity and procedure that give
information about nodal status while avoiding the
potential for over treating low-risk patients and
undertreating patients with metastatic disease. 11

Burke et al.12 published the first report on

identification of SLNs in endometrial carcinoma in
myometrium of uterine fundus at 3 midline sites, dye
uptake was observed in 67% of cases with false negative
rate of 50%.

Holub et al. 13 and Gien et al. 14 reported similar

detection rate of 61.5% and 56% respectively using the
same technique of burke et al. 12 Niikura et al. 15 in their
series of 28 patients injected radioactive tracer around
the tumor under direct visualization by hysteroscopy
the day before surgery, SLNs was identified using gama
probe and removed the detection rate was 82%. Fersis
et al. 16 reported only a 50% detection rate. Bats et al. 17
used cervical injection of the dye with a detection rate
of 80%. Holub et al. 18 used a combination of cervical
and subserosal fundal injections of blue dye and reported
detection rate 80%. Our results of blue dye injection in
cervical and subserosal showed comparable detection
rate of 84.8%.

El-Agwany et al. 19 reported detection rate 86%

in series of 30 patients with early endometrial cancer
having blue dye injection cervical and fundal subserosal,
and 93% detection rate in series of 30 patients with
hysteroscopic injection of blue dye. Barlin et al. 20 in a
study of 498 endometrial cancer patients who received
blue dye cervical injections, SLN was identified in
81% of patients. The SLN correctly diagnosed nodal
metastases in 40/47 patients who had at least one SLN
mapped, for a 14.9% false-negative rate. Youssef, et al.
21
studied 20 cases with fundal injection of blue dye and
reported a detection rate for the SLN of 85% and a
failure rate of 15%. Altgassen et al. 22 reported 92%
detection rate using blue dye injection fundal subserosal
in series of 20 patients. Vidal et al. 23 reported a 62%
detection rate in a series of 66 patients with cervical
injection of blue dye with sensitivity 86% and NPV
98%. Mais et al.
24
reported a 62%detection rate in a series of 34 patients
with cervical injection of blue dye with sensitivity 50%
and NPV 85%. Lopes et al. 25 reported a 78%detection
rate in a series of 40 patients with cervical injection of
blue dye. Holloway et al.26 reported 76%detection rate
in a series of 200 patients with cervical injection of blue
dye with sensitivity 98% and NPV 99%.

An acceptable SLN detection rate varies among

literature, but a detection rate of 80- 90% or greater is
preferred. Khoury-Collado et al.27 studied 115 patients
with endometrial cancer to determine the SLN detection
rate and how many SLN mapping cases a surgeon
811 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 811
811
needed to perform to reach the 90% benchmark. During 5. Schwartz GF, Giuliano AE, Veronesi U, the
the early phase of the study an SLN was identified consensus conference committee. Proceedings of
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Validation of the accuracy of intraoperative
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DOI Number: 10.5958/0976-5506.2019.01676.0

Inorganic Nitrogen Salts in Fibrinolytic Enzyme Production

from Bacillus Megaterium BM 9.1 with Solid State
Fermentation

Mukti Hapsari1, Achmad Toto Poernomo1, Amiruddin Prawita1

1
Pharmacy Department, Faculty of Pharmacy, Airlangga University, Jl. Airlangga No 4-6,
Airlangga, Gubeng, Surabaya city, Jawa Timur

ABSTRACT
Background: The use of fibrinolytic enzymes is necessary as a thrombolytic agent in the treatment
of
vascular disorders. Most fibrinolytic enzymes are obtained from fermented food bacteria.
Objective: This study was conducted to determine the effect of inorganic nitrogen salt against the
production
of fibrinolytic enzyme from Bacillus megaterium BM 9.1.
Method: This experimental study was first conducted on Bacillus megaterium BM 9.1 from coastal waters
which were overgrown with mangrove trees. Media preparation used consisted of 3 types, namely nutrient
agar, nutrient agar with the addition of inorganic nitrogen salts (KNO , NaNO , (NH ) 2SO and NH Cl)
and 3 3 4 4 4
agar with addition of inorganic nitrogen salts (KNO3, NaNO3, (NH4) 2SO4 and NH4 Cl).
Results: From 9 media that have been treated, 100% of them positive in producing fibrinolytic enzymes.
Nutrient Agar (NA) + KNO 3
is the best medium with the highest Fibrinolytic Index (IF) mean,
which is
5.60 ± 0.087. Determining the optimum concentration of potassium nitrate does not mean the
highest
concentration are having the high influence. The optimum fibrinolytic activity of Bacillus megaterium
BM
9.1 are found at 2% potassium nitrate concentration.
Conclusion: Fibrinolytic enzymes can be easily found from some fermented foods, especially the Bacillus
(genus Bacillus). Bacillus megaterium BM 9.1 in the inorganic nitrogen salts is one of the agents that
produce fibrinolytics enzymes which can be used as a therapy for fibrinolytics agents.

Keywords: Bacillus megaterium BM 9.1, Inorganic nitrogen salts, fibrinolytic activity, solid state
fermentation

Introduction Pharmacy Department, Faculty of Pharmacy,

Airlangga University
Every day the body carries out a homeostasis Jl. Airlangga No 4-6, Airlangga,
process. When bleeding occurs will prevent thrombus Gubeng, Surabaya city, Jawa Timur 60115
formation, that is formed will clog the blood flow that Email: [email protected]
carries oxygen to the tissue so that the blood flow stops,
as a result the tissue is not getting oxygen supply.
If

Correspondence Author:
Achmad Toto Poernomo
the thrombus in the blood vessels moves to the brain,
oxygen cannot reach the brain and a stroke occurs.
Stroke can be treated using thrombolytic agents. One
of the thrombolytic agents that are widely used in the
treatment of vascular disorders is fibrinolytic enzymes1–3.

Sources of fibrinolytic enzymes can be obtained

from bacteria, fungi, algae and animals[1]. Bacteria are
the group that produces the most fibrinolytic enzymes.
Most bacteria that can produce fibrinolytic enzymes
are from Bacillus, Streptococcus, Staphylococcus,
Vibrio, Paenibacillus Chryseobacterium Pseudomonas.
Some of them are Bacillus subtilis which is produces
sodiuminase, Streptococcus hemolyticus which is
produces streptokinase and Staphylococcus aureus
which is produces staphylokinase4–6
814 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 814

Previous study it was found that Bacillus put in each test tube that consist of 8 mL and 12 mL and
vallismortis Ace02 isolated from traditional Korean sterilized by autoclave at 121ºC for 30 minutes.17,18.
fermented foods and Bacillus amyloliquefaciens CD-4
were isolated from douchi fermented soybeans Production of Fibrinolytic Enzymes in inoculated
(traditional Chinese food) capable of producing media: The production of fibrinolytic enzymes uses the
fibrinolytic enzymes7,8. In addition, cotton cake and solid-state fermentation method. The media consists of
wheat bran as nitrogen sources of Bacillus cereus NS-2 a based layer and seed layer. The first based layer was
and Bacillus megaterium KSK- made by using 8 mL of fibrinolytic enzyme production
07 isolated from Kisk, traditional fermented food from media which from three variations of nutrient agar
Egypt have produced fibrinolytic enzymes9,10. media which were included in the petri dish and evenly
distributed. While the seed layer is made with 12 mL of
The use of Solid State Fermentation for protease fibrinolytic enzyme production media19.
and amylase production by thermophilic bacteria,
Bacillus sp. BBXS-2 has been done and had been Fibrinolytic activity with Fibrin Plate. Test media
contain fibrinolytic enzymes11. Most of the nitrogen for fibrinolytic enzyme activity were incubated at 37 ° C
available in nature is ammonia (NH ), nitrate (NO -), or
3 3
nitrogen gas (N2). Almost all prokaryotes can use NH3 for 24 hours. Bacteria that produce fibrinolytic enzymes
as their nitrogen source, many also can use NO -, and will provide a clear zone around the hole. The clear
3
some can use organic nitrogen sources, such as amino zone diameter is measured by using the calipers and
acids12. Nitrogen is very important in the growth of determined by its fibrinolytic index .
20

bacteria. This is because nitrogen will be metabolized

to produce amino acids, nucleic acids, proteins and cell Results
wall components13.
First, the growth of Bacillus megaterium B.M 9.1
Bacillus megaterium BM 9.1 is a microorganism in various media for producing Fibrinolytic Enzymes ai
from the Bacillus group, which is still in one genus with observed. After an incubation period of 24 hours at 37 °
Bacillus subtilis which was isolated from mangrove
C there is a growth of bacterial colonies in various
forest14. Where almost all genus bacillus is used as
media that producing fibrinolytic enzymes. Then to
fermented foods there is a content of fibronolytic
determine the fibrinolytic enzyme activity it can be
enzymes. Thus, this study was conducted to determine
the effect of potassium nitrate (KNO ), ammonium measured by the fibrinolytic index. The fibrinolytic
chloride (NH Cl), index is measured by comparing the clear zone formed
on the fibrin plate to
sodium nitrate (NaNO ) and ammonium sulfate (NH the diameter of the well.
) 3 4
2SO4 on Bacillus megaterium BM 9.1.

Materials and Method

Bacillus Microroganism, Bacillus megaterium BM 9.1:
Similar to many proteolytic enzymes originated from
microorganisms, most fibrinolytics also originate from
the genus Bacillus microorganisms15. Study of
Figure 1: Bacillus megaterium BM 9.1 culture on
experiment microorganism16 that were used in this study
nutrient agar + potassium nitrate
are Bacillus megaterium BM 9.1 that been isolated from
the mangrove ecotourism coast of Wonorejo Surabaya,
Indonesia.

Media Preparation and BM 9.1. enzyme production:

The media that been used in this study for culturing
Bacillus megaterium BM 9.1 consists of 3 types of media
as follow, nutrient agar with addition of inorganic
nitrogen sources (KNO , NaNO , (NH ) 2SO and
NH Cl) and 3 3 4 4 4
agar with addition of inorganic nitrogen sources (KNO3 ,
815 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 815
NaNO , (NH ) 2SO and NH Cl). All of the media Figure 2: Fibrin plate activity from nutrient agar +
were ammonium chloride media
3 4 4 4
From Figure 2, which is one example of the growth Conted…
of Bacillus megaterium B.M 9.1 bacteria on nutrient
1st 16,90 4,23
agar + potassium nitrate, a clear zone is observed in
agar + 2nd 16,90 4,23
this media. Figure 4 also shows that the diameter of
NH4Cl 3rd 17,20 4,30
the clear zone in the fibrin plate activity of the nutrient
agar + ammonium chloride is wider than the diameter of Control (-) - -
the well. This clear zone formation shows the activity 1st 16,00 4,00
of fibrinolytic enzymes around the media. Complete agar + 2nd 16,40 4,10
results from 7 media with the combination of nitrogen (NH4)2S 3rd 15,40 3,85
sources from inorganics salts produces a clear zones, Control (-) - -
which means that there are fibrinolytic enzymes in
each medium. Each medium replicated three times with
Table 2: The observation results of the effect
phosphate buffer pH 7.4 as the negative control agent.
from KNO3 Concentration against the activity of
Table 1: Observation results of fibrinolytic enzyme fibrinolytic enzymes
activity on various inorganic nitrogen salts
KNO3 Clear zone Fibrinolytic
Clear zone Fibrinolytic Concentration (%b/v) diameter (mm) Index (FI)
Production Media
diameter (mm) Index (FI) 1st 2
1st 18,30 4,58 2nd 2
0,5%
Nutrient 2nd 18,35 4,59 3rd Control (-) 2
agar 3rd 18,30 4,58
Control (-) - - 1st 2
1st 22,0 5,50 2nd 2
Nutrient 1,0 %
2nd 22,60 5,65 3rd Control (-) 2
agar +
KNO3 3rd 22,60 5,65
Control (-) - - 1st 2
1st 18,25 4,56 2nd 2
Nutrient 1,5%
2nd 18,80 4,70 3rd Control (-) 2
agar +
NaNO3 3rd 18,35 4,59
Control (-) - - 1st 2
1st 19,40 4,85 2nd 2
Nutrient 2,0%
2nd 19,15 4,79 3rd Control (-) 2
agar +
NH4 Cl 3rd 19,70 4,93
Control (-) - -
1st 19,30 4,83 Furthermore, similar observations were made on
Nutrient the production of fibronolytic enzymes and optimum
2nd 19,15 4,79
agar + inorganic nitrogen sources with different concentrations.
(NH4 )2S 3rd 18,60 4,65
The activity test procedure is repeated again from the
Control (-) - -
culture stage and following the stages that are
1st 21,00 5,25 appropriate to the previous procedure. All media
agar + 2nd 21,00 5,25 produce clear zones in the fibrinolytic index.
KNO 3rd 20,00 5,00 Likewise, the most significant
3 Control (-) - - concentration of KNO on the 3 activity of fibrinolytic
enzymes is found1st
in the 2% potassium
18,00 nitrate. 4,50
agar + 2nd 17, 50 4,38
The results of statistical analysis using one way
NaNO 3rd 17,30 4,33 ANOVA resulted in differences in fibrinolytic
Control (-) - - activity
3
of various inorganic nitrogen salts. With the value of
F count 83,085> F table 5,32. The differences in
data
must have a normal and homogeneous distribution. on the production of fibrinolytic enzymes. Potassium
In accordance with the results of one way anova in nitrate, ammonium chloride, ammonium sulfate and
fibrinolytic activity at various concentrations of KNO it ammonium nitrate that have been used as nitrogen
3
also produced differences. source for Bacillus sp. The results show the maximum
growth rate and production of enzymes found in the
The results of the post hoc test analysis shows that
media with potassium nitrate as its nitrogen source 23.
Nutrient Agar (NA) + potassium nitrate has the
significant differences on the production of fibrinolytic After determining the most effective inorganic
enzymes with means difference is higher than the other nitrogen salts for the production of the fibrinolytic
treatment groups. This result is supported by the enzyme from Bacillus megaterium BM 9.1, then the
homogeneous subsets test results which shows if NA + optimum concentration of potassium nitrate for the
potassium nitrate has the significant effect with a value production of the fibrinolytic enzyme Bacillus
of 22.4. Whereas
3
the 2% KNO media has the significant megaterium BM 9.1 will be determined. After the
differences on the production of fibrinolytic enzymes with comparison, the higher concentration potassium nitrate
means difference is higher than the other treatment was accompanied by an increase in fibrinolytic activity
groups. of Bacillus megaterium BM 9.1. The optimum
fibrinolytic activity of Bacillus megaterium BM 9.1 are
Discussion achieved at 2% potassium nitrate, but at 2.5%
potassium nitrate concentration the production rate is
The study was conducted on Bacillus megaterium decreasing. This can be caused by two things. First
BM 9.1 that isolated from the Eco Wisata Mangrove because along with the increase in concentration there is
Coast Wonorejo, Surabaya city, Indonesia14. The results also an increase in the amount of nutrients, so the
from this study is to determine the effect of inorganic bacteria growth rate will increase and the products of
nitrogen salts on the production of fibrinolytic enzymes the metabolites produced are enzymes, will also
and to determine which inorganic nitrogen salts that have increase. But the higher concentration of nutrient not
the significant influence against the production, then always accompanied by an increase in activity, because
fibrinolytic enzyme production media with added an excessive amount of nutrient may lead to death of
inorganic nitrogen salts are made with solid fermentation bacteria.
method.
Second, there is a feedback inhibition mechanism.
In fibrin plate, 4 wells were made using sterile holes At feedback inhibition, the first enzyme activity in the
with a diameter of 0.4 mm. Substances from fibrinolytic biosynthetic pathway is inhibited by the end product
enzyme production medium was inoculated into a well on of the pathway. The first reaction in the biosynthetic
the fibrin plate media. Phosphate buffer pH 7.4 is used as pathway produces an intermediate product used by the
a negative control. The fibrin plate media was incubated next enzyme as a substrate. Thus, inhibition of enzyme
for 24 hours at 37 ° C. The addition of methylene blue to activity in the first reaction can stop the formation of
the media aims to clarify the formation of clear zone, this intermediate products used for the formation of the
is because fibrin is colorless. The clear zone of the fibrin final product 24,25. Finally, the statistical test using one
plate media indicates the ability of the enzyme to degrade way anova showed a significant difference between the
the fibrin substrate and its diameter which is formed in concentration of potassium nitrate and the activity of
accordance with the potential of its fibrinolytic activity21. the fibrinolytic enzyme of Bacillus megaterium BM 9.1.
Degradation of fibrin by fibrinolytic enzymes into soluble Increased potassium nitrate concentration (% b / v) also
amino acids causes the formation of clear zones. causes an increase in fibrinolytic activity.

Enzyme production is influenced by several factors,

Conclusion
such as media, temperature, pH, activators and inhibitors
22
. A good medium for bacterial growth is a medium All inorganic nitrogen salts increases the production
that containing carbon, nitrogen and minerals. Nutrient of the fibrinolytic enzyme Bacillus megaterium BM 9.1.
Agar (NA) is a standard medium for culturing and as The best nitrogen source from inorganic nitrogen salt
metabolite production media for Bacillus sp. In another for the production the fibrinolytic enzyme of Bacillus
case, LSD analysis concluded that the Nutrient Agar megaterium BM 9.1 is potassium nitrate. With the
(NA) + potassium nitrate had the greatest influence
optimum concentration of 2% b / v. So that the Bacillus 8. Peng Y, Yang X, Zhang Y. Microbial fibrinolytic
megaterium BM 9.1 with inorganic nitrogen salts can be enzymes: an overview of source, production,
used as one of the therapies as fibronolytic agents. properties, and thrombolytic activity in vivo.
Applied Microbiology and Biotechnology.
Ethical Clearance: The research process involves
2005;69(2):126.
participants in the survey using a questionnaire that was
accordant with the ethical research principle based on the 9. Bajaj BK, Sharma N, Singh S. Enhanced
regulation of research ethic committee. The present study production of fibrinolytic protease from
was carried out in accordance with the research Bacillus cereus NS-2 using cotton seed cake as
principles. This study implemented the basic principle nitrogen source. Biocatalysis and Agricultural
ethics of respect, beneficence, nonmaleficence, and Biotechnology. 2013;2(3):204-209.
justice. 10. Kotb E. Purification and partial characterization
of serine fibrinolytic enzyme from Bacillus
Conflict of Interest: None declared
megaterium KSK-07 isolated from kishk, a
Source of Funding: This study is done with individual traditional Egyptian fermented food. Applied
funding. biochemistry and microbiology. 2015;51(1):34-43.
11. Qureshi AS, Khushk I, Ali CH, Chisti Y, Ahmad
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DOI Number: 10.5958/0976-5506.2019.01677.2

Relationship Exclusively Giving Mother’s Milk with Growing

Baby

Mustamin Mustamin1,2, Chatarina Umbul3, Shrimarti Rukmini Devy4, Rudy Hartono2

Doctoral Candidate of Health Sciences, Faculty of Public Health, Airlangga University, Indonesia;
1

2
Department of Nutrition, Makassar of Health Polytechnic, Indonesia; 3Department of Epidemiology,
Faculty of Public Health, Airlangga University, Indonesia; 4Department of Health Promotion, Faculty
of Public Health, Airlangga University, Indonesia

ABSTRACT
Breast milk is the best nutrient for infant especially for the newborn. Nutrition in breast milk has benefits
for improving infant’s growth and development. The infant are expected to be the successor of the nation
that has competitiveness and high productivity by getting the best nutrition in the breastmilk. This research
aims to determine the relationship of breastfeeding with infant’s growth and development in Sudiang Raya
District Makassar City. This research is an analytic with cross sectional study design. The population were
all the infant aged 6-12 months in Sudiang Raya distric as many as 192 infants. Total sample were 78
infant. The results showed that the exclusive breast feeding was high (66,7%) compared to the non-
exclusive breast feeding (33,3%). Based on data analysis found that there were a significant relationship
between breastfeeding and infant’s growth based on BB/U index with ρ: 0,000, PB/U index with ρ: 0,001
and BB/ PB index with ρ: 0,010. There were also a significant relationship between breastfeeding and
infant’s development with ρ: 0,000. Giving breast milk to the infant can increase growth and development
so that it can improve their health status.

Keywords: breast milk, infant, growth,

development
Introduction Data from the Ministry of Health of the Republic of
Indonesia (2006) in Kholifah (2014), there are 16% of
Based on data from the 2013 basic health children under five in Indonesia who experience general
research
developmental disorders. Whereas UNICEF (2011) data
for the city of Makassar, breastfeeding <1 hour was
in Fauzia (2015), there are 27.5% or 3 million children
63.6%, breast milk for the past 1-6 hours was 20.5%, under five who experience motor development disorders.
who gave breast milk for the last 7-23 hours was 1.5%, This shows an increase in the number of toddlers who
breastfeeding for the last 24-47 hours was 7.7% and the experience general developmental disorders which
last ≥48 hours was 6.8%2,5,9. include gross motor development disorders, fine motor
skills, hearing loss, intelligence and delayed speech.
Growing and developing are two things that have
different meanings. Growth and development is a Based on the description of the low rates of
continuous process that occurs since conception and exclusive breastfeeding, the importance of the benefits
continues into adulthood. Therefore, in the process of of exclusive breastfeeding and the number of patients
reaching this age the child must go through various with growth disorders in Indonesia which continues to
stages of growth and development15,16,18. increase, the authors are interested in examining the
“relationship between breastfeeding and infant
growth
in the Sudiang Raya area of akassar City”.
M
Corresponding Author:
Rudy Hartono Department of Email: [email protected]
Nutrition, Makassar of Health
Polytechnic,
Wijaya Kusuma Raya Street 46 Makassar, Indonesia
Material and Method

This study is an analytical study with a cross

sectional study design. This research was conducted
in the Sudiang Raya Urban Village in February-June
2017.
820 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 820

The population in this study were 192 infants Conted…

aged 6-12 months. The sample was chosen by random
sampling method and selected 78 babies.The instrument Baby Gender
used was the Pre Development Screening Questionnaire, women 41 52,6
digital scales and fixation boards12. administration of breast milk
Exclusive 52 66,7
The type of data collected consists of two types,
namely primary data and secondary data. Primary data Father’s age
is data obtained from respondents through observation 19-30 years 43 55,1
and interview activities. Mother’s age
19-30 years 58 74,3
The primary data collected is as follows:
Fathers’s education
1. Respondent and family characteristics including
Graduated from high school 52 66,7
name, age, date of birth, parent’s name, address
of parents, work of parents, education of parents, Mother’s education
tribes of parents and religion of parents obtained Graduated from high school 50 64,1
through interviews. Father’s occupation
2. Providing breast milk to babies obtained through private employees 29 37,2
interviews directly with the mother of the baby. Mother’s occupation
3. Baby growth which includes data on body weight housewife 70 89,7
and body length of the baby. Body weight data n1 = 78
was measured using weight scales and body length
data was measured using a fixation board Based on age, it was found that infants who were
conducted directly by the researcher towards the sampled were generally aged between 6-8 months as
respondent. many as 56 infants (71.9%). According to gender, it is
4. Development of infants is assessed based on the known that babies are generally female, as many as 41
suitability of development based on the age of babies (52.6%) and exclusively breastfed as many as 52
the baby at that time. Developmental screening babies (66.7%)
uses the form of the Pre Development Screening It is known that mothers of babies generally aged
Questionnaire conducted by researchers on
between 19-30 years are 58 people (74.3%). While the
parents, closest people or baby caregivers.
baby’s father is generally aged 19-30 years as many
Meanwhile, secondary data obtained in the form as
of the number of babies, schedules and locations of 43 people (55.1%). he majority of parents’ education is
posyandu were obtained through the Sudiang Raya graduating from high school. The mother of a baby with
Health Center in Makassar City. high school education graduated as many as 50 people
Data on body weight and body length were (64.1%) and father of a baby with high school education
processed using the WHO Antro application that as many as 52 people (66.7%). Mother’s work as a
displays the nutritional status of the sample2,3,5,14,15. housewife is 70 people (89.7%), while the baby’s father
Data from the sample development interviews works as a private employee as many as 29 people
were assessed manually based on scoring from the Pre (37.2%).
Development Screening Questionnaire form7,9,10. Data
analysis using SPSS with the chi square test Administration of Breast Milk

Table 2: History of Administration of Breast Milk to

Findings Infants Aged 6-12 Months
Characteristics of Respondents Total
Administration of breast milk
n 1 %
Table 1: Characteristics of Respondents Exclusive 52 66,7
Non Exclusive 26 33,3
Characteristics n1 % Based on the results of research conducted in the
Baby age Sudiang Raya area of Makassar City in infants aged 6-12
6-8 month 56 71,9 months, it was found that 52 infants (66.6%) received
9-12 month 22 28,1
821 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 821
exclusive breastfeeding and 26 exclusive breastfeeding
(33.4%).
Relationship between Giving Breast Milk with Baby The results of statistical analysis prove that there is
Growth a significant relationship between breastfeeding and
infant development in the Sudiang Raya area of
Table 3: Relationship between Giving Breast Milk
Makassar City with a value of p = 0,000. Infants who
with Baby Growth
were exclusively breastfed were 52 babies (66.7%), 49
Administration of infants (94.2%) of whom had development according
breast milk to their age and
Good nutritional
Non p 3 babies (5.8%) had inappropriate developments.
status Exclusive
Exclusive Meanwhile, of the 26 babies (33.3%) who were not
n % n % given exclusive breastfeeding as many as 17 babies
good nutritional status 51 73,9 18 26,1 0,000 (65.4%) had inappropriate development and 9 babies
body length according (34.6%) had the appropriate development.
50 74,6 17 25,4 0,001
to age
body weight according Discussion
52 70,3 22 29,7 0,010
to body length
Mother’s milk (ASI) is the best food for newborns,
The chi-square test results of the relationship
breast milk should also be given as early as possible
between breastfeeding and infant growth based on index
body weight according to age and body length according when the new baby is born. Breastmilk given to babies
to age with a value of ρ = 0,000, body length according after birth until the fourth or seventh day contains
to age index with a value of ρ = 0.001 and index body colostrum which is a liquid that is rich in protein and
weight according to body length with a value of ρ functions to fight infection, thereby reducing
= morbidity and even mortality. The provision of ASI
0.010. According to the results of the study, infants who can also help the survival of babies, especially families
were exclusively breastfed had normal nutritional status from low socio-economic groups by helping to alleviate
based on the body weight according to age index of 51 the family’s economic burden and improve the quality of
infants (98.1%) and those who were not exclusively life for babies from poorly maintained sanitation
breastfed 18 infants (69.2%) had good nutritional environments.
status. Based on body length according to age
index, Based on the results of research conducted in the
50 infants (96.2%) had normal body length and were Sudiang Raya area of Makassar City in infants aged 6-
given exclusive breastfeeding and 17 babies (65.4%) 12 months, it was found that 52 infants (66.6%) received
had normal body length but were not given exclusive
exclusive breastfeeding and 26 exclusive breastfeeding
breastfeeding. Meanwhile, based on the body weight
(33.4%). The provision of exclusive breastfeeding to
according to body length index all infants fed
infants is higher than that of infants who are not given
exclusively breastfed had normal nutritional status while
22 infants who were not given exclusive breastfeeding exclusive breastfeeding according to previous studies.
(84.6%) had normal nutritional status and 4 infants Previous research conducted in the working area of
(15.4%) among them were thin. the health center in Tamalanrea, Makassar, also stated
that more groups were given exclusive breastfeeding,
Relationship between Breastfeeding Mother and namely 29 respondents (56.9%) compared to non-
Baby Development exclusive breastfeeding groups, namely 22 respondents
Table 4: Relationship between Breastfeeding Mother (43.1%)19,20,21. Growth is a quantitative change in the
and Baby Development form of an increase in the number, size, dimensions
of cells, organs and individuals. Not only changes in
Administration of physical size of the body but also the structure of organs
breast milk and brain18,19.
Baby
Non ρ
development Exclusive
Exclusive Based on the results of statistical analysis states that
n % n % there is a significant relationship between breastfeeding
Corresponding 49 84,5 9 15,5 and infant growth in the Sudiang Raya area of Makassar
0,000 City based on the index body weight according to
Not corresponding 3 15 17 85
age, body length according to age and body weight
according to body length. The chi-square test results Optimal child growth is influenced by three basic
of the relationship between breastfeeding and infant needs. The three basic needs are ASUH in the form of
growth based on index body weight according to age fulfilling children’s basic needs in the form of intake
with a value of ρ = 0,000, body weight according to age such as breastfeeding and monitoring growth, ASIH in
index with a value of ρ = 0.001 and index body weight the form of fulfilling children’s emotional needs such as
according to body length with a value of ρ = 0.010. love and treatment from people around their
environment and ASAH obtained through the learning
This is in accordance with previous research where
process20,21.
there was a significant relationship between exclusive
breastfeeding and the growth of 6-month-old infants in
the Working Area of B erseri Pangkalan Kerinci Conclusion
Health Center, Pelalawan Regency. Likewise with the 1. Based on the body length according to age index,
research which states that exclusive breastfeeding 96.2% had normal body length exclusively
affects the nutritional status of infants 9,10,11,14. breastfed and 65.4% had normal body length
but were not given exclusive breastfeeding.
Giving intake other than breast milk for infants Meanwhile, based on the body weight according
under to body length index all infants who were given
6 months of age can increase the risk of infectious exclusive breastfeeding had normal nutritional
diseases and trigger malnutrition. This is because the status (100%) while 84.6% of infants who were
provision of intake other than breastmilk cannot be not given exclusive breastfeeding had a normal
properly digested by the intestines of the newly nutritional status and 15.4% were thin.
developing baby and the non-sterile manufacturing
2. Infants aged 6-12 months who are given exclusive
process can mediate the entry of infectious disease-
breastfeeding in the Sudiang Raya area of
causing bacteria4. Makassar City have a development that is in
Development is a change that occurs quantitatively accordance with their age of 62.8%. Meanwhile,
infants who were not given exclusive
and qualitatively, increasing the ability of the body’s
breastfeeding and had an inappropriate
function to be better and predictable which is an
development of 65.4%.
interpretation of maturation or maturity. Changes
in development occur in gross motor function, fine 3. Giving breast milk to infants aged 6-12
months
motor, cognitive, language, emotional and behavioral in the Sudiang Raya area of akassar City has
M
development as a result of development that is a significant relationship to the growth of infants
influenced with ρ: 0,000 for index body weight according
by the environment1,3,4. to age, ρ: 0,001 for display body according to
age index and ρ: 0,010 for index body weight
The results of statistical analysis prove that there is according to body length index.
a significant relationship between breastfeeding and
4. Giving breast milk to infants aged 6-12
infant development in the Sudiang Raya area of months
Makassar City
with a value of p = 0,000. Infants who were exclusively in the Sudiang Raya area of akassar City has
M
breastfed were 52 babies (66.7%), 49 infants The results of this study are in line with research
(94.2%) conducted in July (2015) where there was a significant
of whom had development according to their age relationship between exclusive breastfeeding and
and exclusive breastfeeding on the development of children
3 babies (5.8%) had inappropriate developments. aged 3-12 months in which 25 infants (41.7%) who were
Meanwhile, of the 26 babies (33.3%) who were not exclusively breastfed had normal development.
given exclusive breastfeeding as many as 17 babies
(65.4%) had inappropriate development and 9 babies
(34.6%) had the appropriate development.
a significant relationship to the development of
infants with ρ: 0,000.

Conflict of Interest: There was no conflict of interest at

the time this research was conducted.

Source of Funding: This study received independent

funding and assistance through the Makassar health
polytechnic Risbinakes fund of the Ministry of Health of
the Republic of Indonesia.

Ethical Clearance: Before the research was conducted,

researchers obtained ethichal clearence from the ethics
commission of health research at the Makassar Health
Polytechnic.
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DOI Number: 10.5958/0976-5506.2019.01678.4

Application of Community Models in an Effort to Control

Smoking Behavior

Ria Rezeki Sudarmin1, Andi Zulkifli2, Masni3, Suriah4, Habibi5, Helmy Gani6, Muhammad Azrul Syamsul6
1
Doctoral Student Program, 2Professor of Epidemiology, 3Lecturer of Biostatistics, 4Lecturer of Health
Promotion and Behavioral Sciences, Faculty of Public Health UNHAS Makassar; 5Lecturer at the
Faculty of Public Health, Alauddin State Islamic University Makassar; 6Lecturer of Hiperkes and
Occupational Safety at the Hiperkes Academy Makassar

ABSTRACT
Smoking is a serious threat to global health, around 1.3 billion tobacco users have nearly 6 million people
who die each year due to diseases that arise from tobacco use. Smoking behavior not only can trigger
NCDs (Non-Communicable Disease) but it also has an effect on economic problems, the more cigarettes
consumed, the higher the costs that will be incurred due to health care and the cost of death due to diseases
that arise from smoking behavior. Comprehensive smoking behavior problems which are caused not only
by psychological and pharmacological factors but also social and environmental needs a community
approach to control these behaviors.
This study aims to collect and analyze articles related to the application of community models in an effort
to control smoking behavior. The design used is the literature review, articles are collected using search
engines such as ProQuest, BMC Public Health, Google Scholar and Plos One. Criteria article used was
published in
2007 -2017. Based on the collected articles, the result is found that the community-based approach can be
applied in the context of controlling smoking behavior as an effort to move the community and to modify
the social environment that can support the creation of behavioral changes and to control smoking behavior.

Keywords: Smoking Behavior, Community Approach, Control

smoking
Introduction where the burden of disease and death from tobacco use
are the biggest problem in the country3.
Smoking behavior has becomes a people’s lifestyle,
compared to rural areas, smokers in urban areas are Based on data from the Global Adult Tobacco
more numerous, this is because urban residents or Survey (GATS) in 2015 from 22 countries there
urban communities have very high social movements 1. were
Smoking remains a serious threat to global health, 879 million smokers with a total of 721 men who
around 1.3 billion tobacco users, nearly 6 million people smoked and 158 women who smoked2. If there is no
die each year from diseases arising from tobacco use2,3. serious prevention in inhibiting the growth of smoking
Tobacco use causes excessive health costs and loss of behavior, in the 21st century, there will be 1 billion
one›s productivity3. About 80% of the 1.3 billion people die of illness due to smoking. It can be concluded
smokers worldwide live in low and middle income that, the higher the consumption of cigarettes the higher
countries, the mortality rate4.

The problem given of smoking behavior is a

comprehensive problem because it is caused not only by
Corresponding Author: psychological factors such as the presence of comfort
Ria Rezeki Sudarmin when smoking, and addiction due to addictive substances
Doctoral Student Program, Faculty of Public Health, contained in cigarettes, but also there are social and
UNHAS Makassar environmental factors that have an important role in
Phone: 085299928286 shaping a person›s smoking behavior, so what is done is
Email: [email protected] not enough to approach individually but in a community.
825 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 825

Handling community-based smoking behavior who do not smoke, especially mothers and children
has been carried out in various countries starting from are usually known as SHS (Secondhand Smoker). The
the implementation of non-smoking regional policies, higher the number of active smokers, the higher the
interventions by providing counseling, and various SHS (Second Hand Smoker) will be. This prompted the
smoking cessation programs5,6. Nierkens (2013) revealed Government to issue a policy related to the protection
that community-based interventions to overcome the of SHS such as prohibiting smoking in certain places
problem of tobacco use are more effective by combining and in vehicles with children21-24. Therefore, to handle
family values7. Helping smokers to quit without creating and control the behavior of smoke, which is quite
an environment that supports them to quit will be alarming, many countries implementing strategies that
difficult for a smoker and can cause them to relapse. can touch the biggest factor causing the increase of
Whereas community-based intervention has a smoking behavior that social environmental factors by
framework that shows that individuals, interpersonal, implementing a strategy based on community.
community, organization and government have an
influence on individual health status and can overcome Forms of community-based smoking behavior
several factors that form smoking behavior control are carried out by various countries, namely the
simultaneously8. Therefore, the handling of application of assessed smoke-free policies can decrease
community-based smoking behavior is considered my smoking prevalence, exposure to SHS and health
effective in overcoming the problem of smoking issues that arise from smoking 24. Brazil is one of the
behavior. Based on the background above, the authors success stories that has succeeded in reducing deaths
are interested in discussing “community model arising from tobacco. A policy strategy called «The Sim
applications in an effort to control smoking behavior”. Smoker Policy Simulation Model» developed in Brazil
has succeeded in overcoming the problem of smoking.
The policy model adopted is starting with raising
Method
the price of cigarettes, strict restrictions on cigarette
The method used in writing this article is a literature advertisements and health warnings, the existence
review. That is a search for literature conducted using an of laws or rules for non-smoking air and increasing
online database that provides free journal articles in PDF smoking cessation programs25.
format: ProQuest, BMC Public Health, Google schooler
Other policies in the form of increasing tobacco tax,
and Plos One. In the initial stages of searching for
intervention in packaging tobacco products, campaigns
journal articles, around 400 articles from the Year 2007
through mass media and prohibitions on cigarette
to 2017 were obtained. Exploration and identification of
advertising at the point of sale, can effect smoking
articles that have relevance will be compiled. Of these,
attitudes and behavior24.26. In America, various media lift
only about 95 articles are considered relevant.
isseu related dangers of smoking on health, the efforts
of the media to support the advocacy process and help
Results policy makers easily to employ the new area without
Based on the results of the articles collected and smoke and to shape public opinion in order to pro-
the analysis of the authors, it was found that smoking restaurant and non-smoking bar
27.

behavior was caused by things that were multi cause. Along with the development of the times,
Smoking does not necessarily become a person›s daily increasingly developing technology is used as a medium
activities. There are various kinds of factors that for delivering information to a broad audience. In New
influence a person to become a smoker that is starting Zealand, using a social media program is called «Online
from lack of knowledge related to the dangers of Smoking Cessation Social Network». The program helps
smoking to health, low education, weak economy, the wider community to obtain information regarding
influence of parents, influence of friends, influence of the dangers caused by smoking and guide smokers to
advertising, influence of substances in cigarettes, stop smoking28.
psychological influences and cultural influences9-20 .
In Indonesia one form of community-based
The most important thing on a problem of smoking
intervention that has been proven to be able to
behavior that their exposure to smoke by people around control
smoking behavior, namely being in a bone-bone village. Community refers to a group of people who share
Bone-bone Village in Enrekang District, South Sulawesi a sense of social identity, general norms, values, goals,
Province is a clear proof of the success of overcoming and institutions32. A community is based on geographical
the problem of smoking with a community-based boundaries (environment, city, or other place), social
approach. The information obtained related to the identity and interests (ethnic groups), or sharing
dangers of smoking for themselves and surrounding political responsibility33,34. Various studies reveal that
people, aroused the heart of one of the Public Figure, the handling of community-based smoking behavior is
namely the Village Head to deal with smoking behavior effective in dealing with smoking behavior in certain
in his village. The strategy used by conducting a survey groups7,35. Community -based interventions not only
previously was related to the community›s opinion take place in society, but also important in guiding into
about cigarettes and then together with other community a characteristic.
leaders, they drew up a plan and invited the community
The following are three principles in community-
to participate to jointly determine the area of s moke-
based interventions; Community-based interventions
free Bone-bone Village29.
are guided by an ecological framework, where
individuals, interpersonal, community, organization, and
Discussion government factors are believed to influence individual
health status, efforts by community-based programs
Smoking behavior has become the lifestyle of
to overcome several factors, either simultaneously
today’s society from a variety of elements either old,
or sequentially8. Community-based interventions are
young, poor or rich. Smoking has a major impact on the
designed to meet community desires and membership-
environment that is unhealthy and has a worse impact on
based interventions. Communities usually begin with
the overall health of the community30. Smoking behavior
needs assessment and developing relationships with
is not only detrimental to the health of the smoker itself
community leaders who understand the strengths and
but also the people around him. Viewed from any angle
problems of the community. The third characteristic
the cigarette remains negative. The more a person of community-based interventions is community
smoked the more death and the emergence of the risk of participation. Community participation refers to the
disease NCD›s (Non-Communicable Disease). process by which individuals and families take an active
part in discussions and activities to improve people›s
The World Health Organization in the Ottawa
lives, services, or resources.
Charter through the International Conference on Health
Promotion in 1986 has provided a framework clearly Community-based intervention by relying on
as an approach to changing people›s behavior towards community participation is considered capable of
better public health by developing health-minded public overcoming multi-causes health problems. The
policies, create an enabling environment, strengthen community-based approach recognizes that health
community action or movement, develop individual problems have several causes, requiring several
skills, and reorient the health care system30,31. interventions to influence individual behavior and
simultaneously changing the social, political and
Given the smoking behavior of the world economic environment based on local health conditions8.
community is very alarming, one of the efforts of the Applying a community-based approach shows that the
WHO (World Health Organization) to overcome the role of family or community leaders influences smokers
current tobacco problem is to invite each country to to stop smoking and reduce exposure to Secondhand
implement the MPOWER strategy3. The strategy Smoker (SHS). In this case, community participation in
MPOWER question are: Monitoring of tobacco use and an environment where a smoker is located can influence
prevention policies, Protect from tobacco Smoker, Offer a smoker to quit35.
help to quit tobacco use, Warn about the dangers of
tobacco, Enforce bans on tobacco advertising, Conclusion
promotion and sponsorship, Raising taxes on tobacco.
Referring to this MPOWER strategy, several countries Community-based interventions are considered
make community-based smoking behavior control effective in overcoming the problem of smoking
programs.
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9. Ngahane BHM, Ekobo HA, Kuaban C.
Conflict of Interest: All authors declared no conflict of Prevalence and determinants of cigarette smoking
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E, Szatkowski L. Tobacco Display and Brand
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DOI Number: 10.5958/0976-5506.2019.01679.6

Level of Type L Metacrylate Acid Copolymer as Microparticle

Matrix Improves Lactobacillus casei Protection against Gastric
Acid

Ayun Dewi Rahayu1, Dwi Setyawan1, Sugiyartono1

1
Department of Pharmacy, Faculty of Pharmacy, Universitas Airlangga, Jl. Airlangga No.4 - 6,
Airlangga, Gubeng, Surabaya, East Java, Indonesia

ABSTRACT
Background: Lactobacillus casei is a probiotic that has an ability to protect the intestine, but is damaged
due to the acid pH in the stomach. A system is needed to provide protection. Probiotic microencapsulation
can provide protection against Lactobacillus casei by increasing the levels of methacrylic acid copolymers.
Objective: The aim of this study is to determine the effect of type L methacrylic acid copolymers
as
microparticle matrix on the protection system of Lactobacillus casei against acidic atmosphere.
Method: Lactobacillus casei probiotic microparticles were made from three formulas using matrix type L
methacrylic acid copolymers with levels in formulas I, II, and III, each of which was 0.50%;
0.75%; and
1.00% by spray drying technique at 120oC inlet temperature.
Results: Moisture content decreased with the increasing levels of methacrylic acid copolymers from
formulas I, II and III with 10.05% ± 0.49; 9.77% ± 0.19 and 7.45% ± 0.11 respectively. In determining
particle size, the results increased simultaneously with the increasing levels of methacrylic acid copolymers
in formulas I, II and III, which were 3.29 ± 0.07; 3.79 ± 0.06 and 4.34 ± 0.13 respectively.
Conclusion: Increasing the level of L type methacrylic acid copolymer as a matrix can increase the
protection
capability of Lactobacillus casei microparticles against gastric acid.
Keywords: Probiotics, Lactobacillus casei, spray drying,
capolymer.

Introduction is a lactic acid bacteria that has antibacterial effects,

immunomodulatory effects, and can be beneficial for the
Probiotics is possible to change the microbial
health of the digestive system (5,6). Lactobacillus casei
balance in the intestine as a first aid for hosts (1).
has an action target area in intestine, but can be damaged
Probiotic bacteria can maintain intestinal health, help
by an atmosphere of stomach acid (7). The development
absorb food, produce vitamins, prevent the growth of
of drug delivery systems aims to minimize the
pathogenic bacteria, and increase host immunity (2).
occurrence of drug degradation, prevent harmful side
Probiotics must be able to get through stomach acid and
effects of drugs, and increase bioavailability and
reach intestine in the amount of 106-107 cfu/ml in order
accumulation of drug fractions in desired body parts (8).
to provide benefits for the host (3,4). Lactobacillus casei
One development of drug delivery systems is to use
microparticles as carriers of active ingredients. The
process of making microparticles is by using
Corresponding Author:
microencapsulation (9).
Sugiyartono
Department of Pharmacy, Type L methacrylic acid copolymer is an anionic
Faculty of Pharmacy, Universitas Airlangga polymer which has been commercially used as an
Jl. Airlangga No.4 - 6, Airlangga, enteric coating for delivery of oral drugs, in which
Gubeng, Surabaya, East Java, Indonesia 60115
the drug will be released into the intestine that has an
alkaline environment (10). Matrix levels are related to the
830 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 830

density and wall thickness of the formed microparticles. Preparation of Lactobacillus casei Probiotic Bacteria
In addition, the high matrix content has an effect on Starters: Ingredients of de Man Ragosa Shorpe (MRS)
increasing the viscosity of the matrix solution and will medium of 5.22 grams of broth were weighed and
increase the thickness of the microparticle wall. The dissolved into 100 ml sterile aquadem, then stirred
density and wall thickness of the microparticles increase until homogeneous. The solution was heated by slowly
the protection power of the microparticles against heating to boil, for one or two minutes. After being
stomach acid (3,6,11).
homogeneous, the solution poured into a test tube
Spray drying technique is a technique of forming container of 10 ml and sterilized at 121ºC for 15
microparticles by dissolving or suspending probiotics minutes. Lactobacillus casei from main stock culture
into a solution or melt polymer and trapped in the form was bred by taking one Ôse of bacteria and then put in 1
of particles (9). Formation of microparticles from spray ml of sterile saline and vortexed until it was cloudy.
drying is done by hot air flowing resulted in water Then, put in 10 ml of MRS sterile broth and
evaporation that occurs faster (9,12). The research using dishwasher at 37ºC for 48 hours. Furthermore, it was
spray drying with an inlet temperature of 98º C resulted taken as much as a few Ôse and swiped on a sterile slant
in the morphology of the microparticles which did not and incubated at 37ºC for 48 hours to become a starter of
Lactobacillus casei which was ready for use. Culture of
meet and the water content was still high. Based on
probiotic bacteria can be used for a maximum of 1
the description above, a study was conducted to obtain
month at 4ºC storage. If the culture stored more than 1
the right type L methacrylic acid copolymer which can
month, probiotic bacteria need to be rejuvenated.
provide protection power from the Lactobacillus casei
microparticles to an optimal gastric acid atmosphere. In Optimization of Lactobacillus casei Growth Time: As
this study the spray drying method was used at an inlet much as 5.22 grams of MRS broth were weighed and
temperature of 120ºC. dissolved in 100 ml sterile aquadem, and then stirred
until homogeneous. Once it become homogeneous, the
Method solution was poured into an erlenmeyer container and
sterilized at
This was a laboratory experimental study. The
121ºC for 15 minutes. The MRS medium of sterile broth
materials used were Lactobacillus casei from the
was added with one Ôse starter of Lactobacillus casei
Center for Food and Nutrition Studies at Gajah Mada
and incubated at 37ºC. Samples were taken at 0, 4, 6, 8,
University, Yogyakarta, Indonesia, type L methacrylic
12, 16, 18, 24 and 48 hours to check pH and the number
acid copolymers, Sodium hydroxide (NaOH), de Man of Lactobacillus casei colonies by determining the Total
Ragosa Shorpe (MRS), Agar medium, sterile Phosphate Plate Count (TPC) of each growth time.
Buffer Saline (PBS), Potassium phosphate (KH2PO4),
Potassium chloride (KCl), Aquadem free of CO2 and Examination of pH of Lactobacillus casei
sterile Aquadem. suspension carried out by Lactobacillus casei culture in
MRS broth was taken for 10 ml at each time of growth.
Identification of type L methacrylic acid copolymers: Then, the measurements were carried out using a
Examination of L-type methacrylic acid copolymers calibrated pH meter using standard buffer solutions.
with FTIR spectrum was carried out using KBr pellet Determination of TPC was carried out by 1 ml
technique. As much as 1 mg of the substance with 100 Lactobacillus casei suspension mixed with 9 ml sterile
mg KBr was mashed homogeneously, then put into a phosphate buffer saline (PBS with pH = 7.4) and
vacuum dryer, then molded with a hydraulic press until vortexed. A 1:10 dilution was carried out in 10 series
a thin translucent plate was obtained. From the results dilutions using sterile PBS, each dilution was piped as
of the examination, the specific wave number values of much as 1 ml to be inserted into a tube containing 10 ml
the compounds analyzed were obtained. Specific wave MRS so that the sterile was then vortexed and poured
numbers obtained stated the presence of certain groups into a plate. The plate was shaken until the sample was
of structures of compounds analyzed (13). evenly dispersed. After the MRS medium solidified, the
plate was incubated at 37ºC for 48 hours.
Lactobacillus casei Microparticle Formulation

Table 1. Design of Lactobacillus casei microparticle formula

No. Materials Function FI FII FIII
1. Bacterial Suspension: Active ingredients 109 cfu/ml 109 cfu/ml 109 cfu/ml
Lactobacillus casei
Sterile aquadem Solvent ad 250 ml ad 250 ml ad 250 ml
2. Matrix solutions:
Acid copolymers type L methacrylate Matrix 5 grams 7.5 grams 10 grams
MRS broth Nutrition 5 grams 5 grams 5 grams
Sterile aquadem Solvent ad 750 ml ad 750 ml ad 750 ml

Note:
F I: Formula with 0.50% type L methacrylic acid copolymer
F II: Formula with 0.75% type L methacrylic acid copolymer
F III: Formula with 1.00% type L methacrylic acid copolymer
Levels of type L methacrylic acid copolymers on F I, II, and III were made from a total of 1000 ml.

Protection Test of Lactobacillus casei Microparticles against Gastric Acid: Test solution was prepared, i.e.
acid
solution of pH of 1.2 and pH of 7 of phosphate buffer saline solution. Acidic solution of pH of 1.2 was made by
mixing
50 ml of 0.2 M KCl solution with 85 ml 0.2 M HCl solution and added aquadem to volume of 200 ml. Phosphate
buffer saline of pH of 7 was then made with a composition of 50 ml 0.2 M KH2PO4 mixed with 25 ml 0.2 M NaOH
solution and added aquadem to volume of 200 ml. In addition, the calculation of viable bacteria using the Total Plate
Count method was incubated at 37ºC for 48 hours. Three-time replications were performed for each formula.

Results

Optimization of Lactobacillus casei Growth Time: The results of Lactobacillus casei pH and ALT log
tests
showing the amount of viability of germs at each incubation time are presented in Table 2.

Table 2: Results of Lactobacillus casei pH and ALT log examination at each incubation time

Period (hours) Replication I Replication II Replication III Mean ± SD

pH
0 5.66 5.66 5.65 5.65 ± 0.01
4 5.55 5.55 5.55 5.55 ± 0.00
6 5.73 5.74 5.73 5.73 ± 0.01
8 5.05 5.05 5.05 5.05 ± 0.00
12 4.48 4.53 4.53 4.51 ± 0.03
16 4.89 4.89 4.88 4.89 ± 0.01
18 4.74 4.75 4.74 4.74 ± 0.01
24 5.38 5.37 5.37 5.37 ± 0.01
48 6.98 6.97 6.98 6.98 ± 0.01
ALT log
0 8.87 9.5 9.49 9.29 ± 0.36
4 8.62 9.85 8.97 9.15 ± 0.63
Conted…

6 11.28 11.56 9.42 10.75 ± 1.16

8 9.66 9.36 9.47 9.50 ± 0.15
12 12.54 11.07 12.76 12.12 ± 0.92
16 11.17 11.58 11.73 11.49 ± 0.29
18 10.48 10.71 10.55 10.58 ± 0.12
24 10.09 10.72 9.99 10.27 ± 0.40
48 9.48 10.49 9.46 9.81 ± 0.59

From the pH test results, it was found that there was a decrease in pH from the growth time of 0 hours until the
growth time of 12 hours. In 12 to 18 hours, the pH was stable and then an increase in pH was occurred. Based on
the results of these tests, it can be seen that the optimum time for Lactobacillus casei (the end time of the
exponential phase or the beginning of the stationary phase) occurred for 12 hours.

Protection power Test Results of Lactobacillus casei Probiotic Microparticles on Gastric Acid Atmosphere

Table 3: Test of Protection power Test of Lactobacillus casei Probiotic Microparticles on Gastric Acid
Atmosphere
Formula Replication I Replication II Replication III Mean ± SD
ALT log after Spray Drying
I 6.45 7.06 7.04 6.85 ± 0.35
II 6.35 7.49 6.89 6.91 ± 0.58
III 7.68 7.30 6.83 7.27 ± 0.45
ALT log of Lactobacillus casei in a microparticle after being exposed to an acidic atmosphere
I 6.46 6.19 6.25 6.30 ± 0.14
II 6.68 6.72 6.45 6.62 ± 0.15
III 7.05 7.22 7.14 7.14 ± 0.09
Protection of Lactobacillus casei in microparticles against acidic atmosphere (%)
I 94.31 90.36 91.24 91.97 ± 2.07
II 96.72 97.30 93.39 95.80 ± 2.11
III 96.97 99.31 98.21 98.17 ± 1,17
From these data, it can be seen that the increase in The mixture of Lactobacillus casei suspension
matrix levels of type L metacrylate acid copolymers with matrix solution and MRS was carried out by
(0.50%, 0.75%, and 1.00%) can increase the percentage microencapsulation using spray drying method and the
of protection power in the Lactobacillus casei pre-adaptation process was firstly carried out. (15). The
microparticles. three microparticle formulas produced had a moisture
content (MC) higher than the required content of
Discussion probiotic microparticles which was not more than 4%
(16)
. The moisture content of spray drying microparticles
Increased matrix levels used can cause an increase can be influenced by the inlet temperature. An increase
in the thickness and density of the matrix wall. The in inlet temperature can cause a decrease in moisture
higher methacrylic acid copolymer causes more content (17).
hydrogen bonding carboxylic groups to be formed
and will increase the density of the microparticle wall The difference in matrix levels will affect the
(14)
. The density and wall thickness of a high characteristics of the probiotic microparticles that
microparticle causes an increase in the protection power are formed. Probiotic microparticles that meet the
of the microparticle against stomach acid (3). characteristics of probiotic microparticles range from
1-1000 μm, ideally less than 100 μm. (3,18). Entrapment Ethical Clearance: The research process involves
efficiency is carried out to determine the amount of participants in the survey using a questionnaire that was
probiotics coated in microparticles and show the content accordant with the ethical research principle based on the
of probiotics as active ingredients (19). Factors that regulation of research ethic committee. The present study
influence entrapment efficiency are include solubility was carried out in accordance with the research
of the polymer in solvents, matrix content, and solvent principles. This study implemented the basic principle
removal rate. (1). High matrix levels will increase the ethics of respect, beneficence, nonmaleficence, and
protection of probiotics against temperature. justice.

Spray drying is a single closed system process Conflict of Interest: The author reports no conflict
that can be used for a variety of materials. The of
medicinal ingredients are dissolved or suspended into interest of this work.
suitable solvents containing polymers. The solution or
Source of Funding: This study is done with individual
suspension is atomized into the drying chamber and the
funding.
microparticles are formed as atomization droplets which
are dried by hot air. The results are highly influenced by
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DOI Number: 10.5958/0976-5506.2019.01680.2

The Influence of Tell Show Do Method Based on

Individualized Educational Program (IEP) to the Tooth-
Brushing Behavioural Change among Slow Learner Children
in Bukittinggi, Indonesia

Febrian1, Ghina Ukhtia Fajrani1, Arymbi Pujiastuty1

1
Faculty of Dentistry, Andalas University, Jl. Perintis Kemerdekaan No. 77 Padang, Sumatera Barat,
Indonesia

ABSTRACT
Objectives: Slow learner children are the largest population of children with special needs in Indonesia,
including 80.64% have poor oral hygiene caused by inappropriate tooth-brushing. An advance learning
method needs to take behavioural change of children’s tooth brushing habit. This study aims to investigate
the Tell Show Do Method based on Individualized Educational Program (IEP) affected the behavioral
changes of tooth brushing among slow learner children in elementary school Bukittinggi, Indonesia.
Method: This was a quasy experimental study with one group pre-test and post-test design. Total of 32
slow
learner children, grade 4-6 were included in this study. Data was analyzed by using Paired McNemar
test.
Results: The latest behavioural change on cognitive, affective and psychomotor became different into good
category. Hence, there is significant difference before and after counselling (p=0,000). So, it is concluded
that Tell Show Do Method based on Individualized Educational Program (IEP) affect behavioural changes
regarding tooth brushing among slow learner children in elementary school Bukittinggi, Indonesia.

Keywords : Counselling, Tell Show Do, IEP, Slow Learner, Behavioural

Change

Introduction Education and counselling could improve children

oral hygiene.3 There is a need of early counselling with
Dental Caries is one of the most common oral
proper method according to their ability, mainly in
hygiene issue in the world, including in Indonesia. One
of the main factor is inappropriate of tooth brushing children with special needs. Slow learner children are
technique. According to RISKESDAS 2013, only 2,3% categorized into children with special needs, but they
people in Indonesia use correct method of tooth can learn something as long the given method is a proper
brushing.1 It may affect oral hygiene neither healthy method. So thus proper education and counselling
person nor children with spesial needs. This study method for this population is needed.
concerned about slow learner children.4 Slow learner
children are a group of children with IQ of 70-90 One of the method of pediatric dentistry is Tell
(slightly below average) without mental retardation. Show Do method.6 Tell Show Do is the most effective
Fourteen percent children in Indonesia are slow learner non-pharmalogical techniques use by pediatric dentist.7
and 80,64% of them have poor oral hygiene.1 This method is done by telling, introducing, and
showing dental hygiene procedure to children.
Corresponding Author: Information can be delivered verbally with language that
Febrian easy to understand, and also by giving the children
Faculty of Dentistry, Andalas University, opportunity to observe and apply the given
Jl. Perintis Kemerdekaan No. 77 Padang, information.6,8 Study by Arun Sharma and Rishi Tyagi
Sumatera Barat, Indonesia in India in 2011, suggested that Tell Show Do method
Email: [email protected]
showed positive impact and very effective to modify
children behavior.9
836 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Slow learner children need special technique, unlike Materials and Method
normal children.10 Individualized Educational Program
This was a quasy experimental study with one
(IEP) is a program made to serve children with special group pre testpost test design. Pre test was done at the
needs. This program is adjusted for each individual, beginning of the study by using a questionnaire, and
according to their ability, method, and learning speed so respondents were given treatment using Tell Show Do
one can understand the given subject. In other word, this based on IEP. Before counselling, first step to do was
recognized the characteristics of slow learner children
learning technique gives children chance to learn based
and grouped based on the results of that assessment.
on their ability so thus we can maximize their ability Then, counselling given individually with Tell Show Do
as well.10 In Indonesia, this program was commonly method. At the end, evaluated the effect of counseling
used as an educational program to serve children with using post test with the same questionnaire. This study
took place in Al Azhar Elementary School Bukittinggi,
spesial needs including slow learner children. Whereas
West Sumatera, Indonesia on February 2018. Fourth-
combination of Tell Show Do method to IEP is a new sixth grade slow learner students were recruited. Data
innovation that was never been done before. So, this was analysed using Paired McNemar to investigate
study aims to investigate Tell Show Do based on IEP signification of each behavioural domain including
with behavioural changes on tooth brushing, among cognitive, affective, and psychomotor, and considered
significant if p < 0,05.
slow learner children.

Results

Tabel 1: Differences of behaviour domain before and after counselling using Tell Show Do method based on
IEP (n = 32)
Before Counselling After Counselling
Behavior
Good Poor Good Poor P value
Domain
n % n % n % n %
Cognitive 12 37,5 20 62,5 30 93,75 2 6,25
Affective 11 34,37 21 65,63 30 93,75 2 6,25 0.000
Psychomotor 10 31,25 22 68,75 29 90,63 3 9,37
Based on table 1, frequency distribution of affective, and psychomotor. Firstly, counselling with
good categories increased after counselling. Before the method of Tell Show Do based on IEP was done by
counselling, almost respondent had poor category to recognizing the characteristics of slow learner children.
use tooth-brushing technique in cognitive, affective Secondly, children with the same characteristics were
and psychomotor domain (62.5%, 65.63%, 68.75%) classified into the same group. Then, they were given
respectively. On other hand, cognitive, affective and counselling on each group by using the Tell, Show and
psycomotor domain decreased in poor category after Do method gradually. Counselling in each group was
counselling with 93.75%, 93.75%, 90.63% respectively. different, depending on the level of children’s ability, so
So, there were significant difference of behaviour change it can be absorbed quickly or even takes a long time.
before and after counselling using Tell Show Do method Hence, this method is called by IEP.
based on IEP with p value 0,000.
The cognitive level was changed significantly due
to counselling design according to the level of children’s
Discussion
ability. The results of this study similar to the theory by
Study showed that there were behavioural changes the American Academy of Pediatric Dentistry (AAPD)
of tooth brushing among slow learner children after claimed that the Tell Show Do method can changes
counselling using Tell Show Do method based on IEP children’s knowledge of dental health care because of
observed by behavioural domain including cognitive, clearly explanations to children about the dental
health
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 837
procedures at the “Tell” stage and shown the procedure et al in United States argued that IEP was an appropriate
to make them easier to understand at the “Show” and and an effective program for children with special needs
“Do” stage.11 The significant change of the cognitive level because it was adjusted with individual needs.15 Ruble
in this research was also caused by appropriate service et al from United States also argued that IEP was the
education to slow learner children with IEP. The results only program compatible to treat children with special
of this study is similar to Budiyanto et al in 2013 stated needs due to children’s needs and education based on
that the IEP is an efficient program to provide their interested and understanding.16
knowledge in children with special needs and can be
absorb well. The program is implemented individually on Conclusion
each slow learner children according to the level of
ability.12 Tell Show Do method based on Individualized
Educational Program (IEP) has significant correlation
In affective level category after counselling, there with behavioural change on tooth brushing among
were significant changes to better affection than before slow learner children in elementary school Bukittinggi,
counselling caused by education process of knowledge Indonesia.
could produce good attitude. It also supported by
Notoatmodjo 2010, respondent with good cognitive Ethical Clearence: Taken
level also had good affective level too.3
Conflict of Interest: There is no conflict of interest
Significant change of psychomotor level toward to of
good category because the counselling not only giving this study.
raw material at Tell and Show stage, but also giving
Source of Funding: This study was counducted by
opportunity to practice direct knowledge among slow
self- funding.
learner children. Meanwhile, Do stage can stimulate
their motor skills in brushing action. The children’s
motor skills can be stimulated by practical activities of REFERENCES
their knowledge. Its supported by the AAPD in 2015 1. Riskesdas. Badan Penelitian dan Pengembangan
stated that the Tell Show Do method can give children Kesehatan Kementerian Kesehatan RI. Jakarta;
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precisely at the Do stage, so it more easily to understand
2. Arianto, Shaluhiyah Z, Nugraha P. Perilaku
and implement the procedure.11
Menggosok Gigi pada Siswa Sekolah Dasar
Thus, the behavioural improvement was due to Kelas V dan VI di Kecamatan Sumberejo. Jurnal
children’s awareness to change their behaviour through Promosi Kesehatan Indonesia. 2014; 9 (2).
health counseling.1 Tell Show Do method can be used 3. Notoatmodjo. Ilmu Perilaku Kesehatan. Jakarta:
in behavioral management in pediatric dentistry.6,8,13 Rineka Cipta; 2010
This study similar to Arun Sharma and Rishi in India,
suggested that Tell Show Do method had positive effect 4. Sutijan. Mengajar Peserta Didik Lambat Belajar
and can be used on behavioural management in pediatric di Sekolah Dasar. Jurnal Rehabilitasi dan
dentistry.9 Tell Show Do also can be used to explain oral Remediasi.
hygiene to children with special needs. Not only verbal 2011; No 2 ISSN 0854-0020.
information and easy language, but also method enables 5. Sugiarti R dan Pribadi AG. Analisis Faktor yang
children to observe and apply their knowledge under Mempengaruhi Keberhasilan Belajar Siswa Slow
supervision.14 Learner di Sekolah Luar Biasa Semarang. Jurnal
Psikologi Proyeksi. 2012; 6(2): 1.
Tell Show Do method in this study was done
through IEP. Study showed learning through IEP 6. Singh H, et all. Techniques for the Behaviors
increased behavioural changes of tooth brushing among Management in Pediatric Dentistry. International
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theory by the ministry of education and cultural in 2013, 7. Sharma K, Malik M, Sachdev V. Relative efficacy
suggested IEP could serve children with special needs. 13 of Tell-Show-Do and live modeling techniques on
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suburban Indian children during dental treatment 13. Farhat MH, Hafouche A dan Souaid P.
based on heart rate values: a clinical study. Techniques for Managing Behavior in Pediatric
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8. AAPD. Guideline on Behavior Guidance for the Rates During Treatment. Journal Canadian
Pediactric Dental Patient. Reference Manual. Dental Association
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9. Sharma A and Tyagi R. Behavior Assesment of 14. Vinodhini BJ, Asokan S, Priya PR dan John B.
Children in Dental Settings: A Restrospective It’s Lame to Tame-Children with Spesial Health
Study. International Journal of Clinical Pediatric Care Need. Journal of Academy of Dental
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DOI Number: 10.5958/0976-5506.2019.01681.4

Hyperglycemic and Hypertension are Major Component of

Metabolic Syndrome that Caused Circulatory Morbidity in
Hajj Pilgrims

Iche Andriyani Liberty1,2, Nasrin Kodim2, Mukaramah2

1
Department of Public Health and Community Medicine, Medical Faculty of Sriwijaya University,
Palembang, Indonesia; 2Department of Epidemiology, Public Health Faculty of Universitas Indonesia,
Depok Indonesia

ABSTRACT
Hajj is a community that needs special attention, the series of worship activities during in the holy places
in Makkah and Madinah must be supported by physical and mental prime. One of the health problems
has related to circulatory disease. This study presents the impact of metabolic syndrome (hyperglycemic,
hypertension, and obesity) that caused circulatory morbidity in Indonesian Hajj Pilgrims. The design study
is Retrospective Cohort, conducted on 152,429 Indonesian pilgrims departing in the Hajj season
2016/1437H sourced from The Siskohatkes data of the Ministry of Health of the Republic of Indonesia.
The prevalence of metabolic syndrome (hyperglycemic, hypertension, and central obesity) on Indonesian
pilgrims 1.6% and significant differences were found in all characteristic: sex, age, employment, and
education, BMI, istitha’ah, and smoking behaviour. Hyperglycemic had greater HR than hypertension and
central obesity with HR of
2.06 (1.63-2.60) adjusted by BMI, smoking, age, and sex as a risk of inpatient care. While, hypertension
had greater HR than hyperglycemic and central obesity with HR 2.04 (1.99-2.09) adjusted by smoking, age,
and sex as a risk of outpatient care in the holy places in Makkah or Madinah. Regulation for additional
history of drugs consumed on screening of pre-existing disease before departure is needed.

Keywords: hyperglycemic, hypertension, Mets, hajj, morbidity

Introduction Circulatory disease, which is customarily defined
as those causes of mortality and morbidity with
Metabolic syndrome (MetS) is a complex
International Classification of Diseases 10th revision
disorder characterized by abdominal obesity, impaired
(ICD10) codes I00-I99 (or equivalently the International
glucose metabolism, atherogenic dyslipidemia and
Classification of Diseases 8th or 9th revision (ICD8,
hypertension.1,2 A systematic review of epidemiologic
ICD9) codes 390–459). Major types of circulatory
data from the Middle East reports a prevalence of
disease are Arteriosclerosis, Cardiac valve diseases,
MetS in men of 20.7-37.2% and 32.1-42.7% in women.
Cardiac arrhythmias, Cardiomyopathy, Cerebrovascular
Increasing trend of circulatory disease followed by
disease (CeVD), Hypertensive disease, Ischemic heart
ignored active health policies to control the risk factors,
disease (IHD), Pericarditis.3
but studies are available that discusses the risk factors of
circulatory disease has not been found, especially that Hajj is a community that needs special attention.
associated with metabolic syndrome. 1,3, 4 the series of worship activities during in holy places in
Makkah and Madinah must be supported by physical
and mental prime. One of the health problems facing
Corresponding Author: the congregation is related to circulatory disease. Blood
Iche Andriyani Liberty glucose, triglyceride, HDL, LDL, cholesterol, blood
Department of Public Health and Community Medicine, pressure, and physical anthropometry such as weight
Medical Faculty of Sriwijaya University Palembang, and height and abdominal circumference are some of
Indonesia the variables that can be an indicator of cardiometabolic
Email: [email protected] risk and have been measured before pilgrims leave. Hajj
840 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 840

pilgrims who are large populations are expected to define overweight were underweight (<18.5); Normal
become populations representing the community in weight (18.5 -24.9kg/m2); Overweight (25.0-29.9kg/
providing predictive values r elated to metabolic m2); Obesity Grade I (30.0-34.9kg/m2); Obesity Grade
syndrome and their impact on circulatory morbidity that II (35.0-39.9kg/m2); and Extreme Obesity as BMI of
are major problems and causes of major deaths ≥40 kg/m2. Based on the Regulation of the Minister of
worldwide. Health of the Republic of Indonesia Number 15 of 2016
on Istitha’ah explained that the ability to perform the
Method pilgrimage physically, mentally and provision.

Study Design and Study Protocol: This study used Statistical Analysis: Processing and analysis were
secondary data SISKOHATKES 2016 with performed using statistical program STATA 15.
Retrospective Cohort Study design, conducted on all Univariate analysis was performed to see the distribution
Indonesian pilgrims departing on the Haj season of each variable and parameter estimation of the
2016/1437H. The target population of all Indonesian variables presented in tables, and bivariate analysis
pilgrims departing during the Hajj season 2016 and using Chi Square test. Multivariate analysis using Cox
recorded in the initial examination SISKOHATKES Regression to determine the hazard ratio of
cardiometabolic factors on the impact of morbidity from
2016. Population study has 152,429 pilgrims in 2016
cardiovascular disease. Before the variable entered in
who conduct medical tests.
multivariate analysis, first tested proportional hazard.
Measurements and Calculations: Before departure, all The test is conducted to determine whether the
Indonesian pilgrims are required to visit a government candidate variables has a proportional hazard over time
health facility for a medical examination and to receive or not.
a pocket book that outlines their health condition.
Clinical identification of patients with the features of Findings
MetS was based on the criteria proposed by the NCEP-
All 15,429 Indonesian pilgrims were aged 18 years
ATPIII (National Cholesterol Education Program Adult
or more. where the prevalence of metabolic syndrome
Treatment Panel III). Patients were considered to have
was 1.6% (2,450 pilgrimages). Most pilgrims had
MetS when three of the following five criteria were met:
metabolic syndrome were female 1.8% and aged 50-59
1) waist circumference ≥ 102 cm in men and 88 cm in years (Table 1). The prevalence of Mets (hyperglycemic,
women; 2) fasting hyperglycemic ≥ 110 mg/dL or using hypertension, and central obesity) on Indonesian
diabetes medications; 3) triglycerides ≥ 150 mg/dL or pilgrims 1.6% and significant differences were found in
taking triglyceride lowering agents; 4) HDL cholesterol all characteristic: sex, age, employment, and education,
< 40 mg/dL for men; < 50 mg/dL for women or taking BMI, istitha’ah, and smoking behavior. Majority
cholesterol-lowering agents; and 5) hypertension pilgrims with Mets were female (1.8%), aged 50-59
(systolic blood pressure ≥130 diastolic blood years (2.15%), military/police (2.0%), low education
pressure (1.7%), extreme obesity (3.0%), not qualified
≥85) or using antihypertensive medication. Body mass temporarily of istitha’ah (2.8%), and did not smoking
index (BMI) was calculated as weight (kg) divided (1.7%).
by height (m) squared (kg/m2). The criteria used to
Table 1: Indonesian Hajj Pilgrims Characteristic and Metabolic Syndrome

Mets Total
Variables P-value
Yes (n = 2,450) No (n = 149,979) (n = 152,429)
Sex
Female 1,563 (1.8%) 83,156 (98.2%) 84,719
0.000
Male 887 (1.3%) 66,823 (98.7%) 67,710
Age
<40 years 42 (0.3%) 14,749 (99.7%) 14,791
40-49 years 408 (1.1%) 36,905 (98.9%) 37,313
0.000
50-59 years 1,104 (2.1%) 51,695 (97.9%) 52,799
>60 years 896 (1.9%) 46,630 (98.1%) 47,526
Conted…

Employment
Military/Police 27 (2.0%) 1,328 (98%) 1,355
Farmer 448 (1.4%) 31,882 (98.6%) 32,330
0.000
Goverment Employment 1,021 (1.5%) 66,261 (98.5%) 67,282
Others 954 (1.9%) 50,508 (98.1%) 51,462
Education
Low 958 (1.8%) 51,813 (98.2%) 52,771
Middle 870 (1.6%) 53,541 (98.4%) 54,411 0.000
High 622 (1.4%) 44,625 (98.6%) 45,247
BMI
Under weight 16 (0.2%) 7,160 (99.8%) 7,176
Normal weight 827 (1.1%) 72,044 (98.9%) 72,871
Over weight 1,136 (2.0%) 54,822 (98.0%) 55,958
0.000
Obese grade I 370 (2.8%) 12,948 (97.2%) 13,318
Obese Grade II 75 (3.2%) 2,235 (96.8%) 2,310
Extreme Obesity 26 (3.3%) 770 (96.7%) 796
Istitha’ah
Qualified 1,034 (1.6%) 62,369 (98,4%) 63,403
Qualified with assistance 224 (2.6%) 8,241 (97.4%) 8,465
0.000
Not qualified temporarily 1,192 (2.8%) 41,749 (97.2%) 42,941
Not qualified 0 (0.0%) 48 (100%) 48
Smoking
Yes 187 (1.1%) 16,403 (98.9%) 16,590
0.000
No 2,263 (1.7%) 133,576 (98.3%) 135,839
*Chi Square test. sig = 0.05

Table 2 from multivariate analysis with cox regression showed the results obtained that hyperglycemic had
greater HR value than hypertension and central obesity with HR of 2.06 (1.63-2.60) adjusted by BMI, smoking, age,
and sex. This means that pilgrims who before departure have clinical considents with hyperglycemic have a risk of
2.06 times to have circulatory disease and hospitalized (inpatient care) while performing the pilgrimage in the holy
places in makkah or madinah.

Tabel 2: Multivariate Analysis of Associated Mets and Inpatient Care Caused of Circulatory Disease
Variables
Inpatient Care
Yes (n = 1,847) No (n = 150,582) (n=152,429)
Total 95%
HRCI
p-value
Hyperglycemic
Yes 80 (0.9%) 8,734 (99.1%) 8,814 2.06
No 593 (0.4%) 143,022 (99.6%) 143,615 (1.63-2.60)
0.000
Hypertension
Yes 315 (0.8%) 39,664 (99.2%) 39,979 1.73
No 358 (0.3%) 112,092 (99.7%) 112,450 (1.48-2.02)
0.000
Central Obesity
Yes 353 (0.4%) 95,845 (99.6%) 96,198 0.8
0.000
No 320 (0.6%) 55,911 (98.4%) 56,231 (0.65-0.95)
*Adjusted HR by BMI, smoking, age, and sex.
Different results (table 3) were obtained in outpatients during the holy places in makkah or madinah, where
prior to hypertension had greater HR than hyperglycemic and central obesity with HR 2.04 (1.99-2.09) adjusted by
smoking, age, and sex.

Tabel 3: Multivariate Analysis of Associated Mets and Outpatient Care Caused of Circulatory Disease
Outpatient Care HR
Variables Total Sig
Yes No 95% CI
Hyperglycemic
Yes 2,085 (23.7%) 6,729 (76.3%) 8,814 1.21
0.000
No 25,405 (17.7%) 118,210 (82.3%) 143,615 (1.16-1.27)
Hypertension
Yes 12,868 (32.2%) 27,111 (67.8%) 39,979 2,04
0.000
No 14,622 (13.0%) 97,828 (87.0%) 112,450 (1.99-2.09)
Central Obesity
Yes 27,490 (18.0%) 77,541 (80.6% 96,198 1.09
0.000
No 8,833 (15.7%) 47,398 (84.3%) 56,231 (1.06-1.13)
*Adjusted HR by smoking, age, and sex.
Discussion and results in many diseases include hyperglycemic.
Increased insulin secretion is observed in both sexes,
MetS is an increasingly common cause of morbidity
both of which have sufficient compensation to approach
and mortality and has been reported with many
the normal curve, derived from the control of normal
postulated pathophysiologic diseases. Prevalence of
weight on the subject. Insulin sensitivity disorders and
metabolic syndrome is high among Asians and is rising,
insulin secretion are equally strong and similar in both
particularly with the adoption of modernized lifestyle.2
sexes. The evidence is confirmed as well as introducing
The most commonly associated with insulin, along with
age and BMI as covariates into the entire population:
proinflammatory, prothrombotic, and low grade
that is, insulin sensitivity decreases with increasing BMI
oxidative status.5 In this research, age and sex has
in the same rate for men and women in all categories of
associated with Mets and in multivariable analysis, age
glucose tolerance; while insulin secretion increases with
is confounding variable. With respect to age, MetS
BMI on a faster rate in men, it is better to compensate
prevalence rates were higher in older, relative to
for the increase insulin resistance. This trend may partly
younger, elderly subjects; however, this difference was
explain why, in general, women are better at insulin
nonsignificant. In general, the prevalence of MetS
sensitivity than men in normoglycemic states. This may
increases with age.6
be related to sex hormones and their receptors, different
Aging is one of the diverse and functional that body fat distributions and associated biomarkers, such
occurs from time to time. These terms also affect as higher adiponectin. Estrogen shows a protector effect
biological functions after reaching their maximum of cell apoptosis, stimulates the beta cell secretion and
potentials. During aging, sex steroid hormone is reduced increased insulin sensitivity with antidiabetic effects
and sex hormones that bind globulin increase, the rate mainly described to ERα.
9

of decrease in free hormone levels. Therefore, the Meta-analysis of prospective cohort studies found
reproductive and non-reproductive actions of sexual
in populations with MetS defined by NECP have a
steroid hormones decreased significantly. However,
significantly higher risk of incident stroke than those
there are major differences in the prevalence, timing of
without MetS and higher in women compared with
onset and severity of many conditions such as
men, which was in agreement with a few studies.10
metabolism and disease, which are different from men
and women and protective roles. 7,8 Proper identification of Mets in hypertension can
provide better predictions of poor cardiovascular events
There is more evidence that different sex is and models that can be used for specific factors.11
important in epidemiology, pathophysiology,
treatment
Each component of the MetS is an independent risk Ethical Clearance: Ethical clearance and permission of
factor for cardiovascular disease, together producing this research was obtained from the Indonesian Ministry
a wide spectrum of vascular and cardiac diseases.12 of Health with the LB.02.03/1/1429/2018 approval
Each component of cardiovascular disease, related to number.
the spectrum of cardiovascular conditions including
microvascular dysfunction, coronary atherosclerosis and Conflict of Interest: All the authors have disclosed
no
calcification, cardiac dysfunction, myocardial infarction,
potential conflicts of interest relevant to this article.
and heart failure.13
Source of Funding: source of funding for this research
The obesity relationship observed with hypertension
and publishing this article was from Universitas
makes the body work exploring the causes and effects of Indonesia.
obesity on the heart. Chronic weight gain and adiposity
can lead to significant neurohormonal changes and
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DOI Number: 10.5958/0976-5506.2019.01682.6

The Determinant Factors of Child’s Immunization Status:

A Cross Sectional Study on the Dayak Pitap Tribe in the
District of Balangan Indonesia

Ida Hastutiningsih1, Oedojo Soedirham2, M. Bagus Qomaruddin2, Boerhan Hidayat3

1
Doctoral Student of Public Health Program, 2Lecturer, Department of Health Promotion and Behavior
Science, Faculty of Public Health, 3Professor of Medicine, Department of Pediatric, Faculty of Medicine,
Airlangga University, Surabaya, Indonesia

ABSTRACT
Background: Even if the immunization coverage in a region is high, but the unimmunized child gathered
in one location, then the benefit from herd immunity developed will not be gained by the child in that
location so the risk for outbreak vaccine preventable diseases is high. So in order to solve this problem, it is
important to reach this under vaccinated population and increase the child’s immunization status of the
population. The aims of this research were to describe the immunization status and its determinant factors
that influenced the child’s immunization status of Dayak Pitap tribe in the district of Balangan Indonesia
Method: A cross sectional study conducted in May to June 2018 which included the interview using a
questionnaire with the mother of 12 – 35 month old child in all house hold in Dayak Pitap tribe. The
independent variables were the mother’s education level, the mother knowledge about immunization,
the history of mother immunization status during pregnancy and the childbirth attendant and the cultural
determinant namely the aruh ritual, the papantang and the use of the samban, whereas dependent variable
was the child’s basic immunization status. The uni-variable analysis and logistic regression analysis
employed as the research analysis method.
Result: The complete child’s immunization status coverage was 48%. The determinant factors that
significantly influenced on the child’s immunization status were the mother immunization knowledge level
(p=0.000), the history of mother immunization during pregnancy (p=0.033), the history of birth attendant
(p=0.000) and the using of samban by the children (p=0.012).
Conclusion: In order to gain the better child’s immunization status coverage of the Dayak Pitap tribe, it is
important to develop combination interventions to give better knowledge about immunization to the mother
with the tailor made material, promote birth attendant labor and reach the pregnant mother for
immunization.

Keywords: Child immunization, indigenous tribe, cultural determinant

Introduction the children get benefit from the protection, including

not immunized children and children who had already
One of the purposes of immunization is to develop
immunized but failure in developing antibody that
herd immunity in the community that can make all
can be caused by the child condition such as virus
and

bacterial infection(1), the nature and condition of the

Corresponding Author: vaccine itself(2) ”ISBN”:”1873-2518 (Electronic(3) and
Oedojo Soedirham the abnormalities of the immune system such as the
Department of Health Promotion and Behavioral hypogammaglobulinemia, other genetic factors and other
Sciences, Faculty of Public Health, causes that still poorly understood (4). In order to develop
Airlangga University, Surabaya, Indonesia the herd immunity, high uptake of fully immunized
Email: [email protected] children must be obtained. The problem is every country
846 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 846

has population groups that are not fully immunized that the violator. The violation of papantang also believed
have a consequence in the risk of vaccine-preventable by the community can cause misfortunes and illnesses.
disease outbreak. A samban is a kind of amulet that worn as a necklace by
the child after conducting a sacred ritual and believed
Actually, in case there is a child, who is getting an
can protect children from illnesses.
infection of vaccine preventable diseases, but the high
uptake of immunization has been obtained and the herd This research conducted in the Dayak Pitap tribe
immunity has been developed, the other children will be that settles in the slope of Meratus highlands in Tebing
protected because the spread of the infection had already Tinggi sub districts of Balangan, South Kalimantan
blocked. However, this only works if unvaccinated child Province, Indonesia. Although this tribe registered as
is scattered across geographical areas. If the unvaccinated Hinduism which is called Hindu Kaharingan, very little
child is gathered in one location, such as in the Dayak aspect of Hinduism exists in their everyday lives. They
Pitap tribe, diseases can cause large outbreaks – even if still maintain their belief and culture as animism and
the region or province or national vaccination coverage is dynamism tribe.
high.
Hence, the aim of this paper is to describe the
In this purpose, it is important to make sure that the immunization status and its determinant factors that
immunization coverage in the remote areas is also high. influenced the child’s immunization status of Dayak
However, based on the preliminary study that conducted Pitap tribe in the district of Balangan Indonesia.
in Dayak Pitap on January to March 2017, the fully
immunized children coverage of the Dayak Pitap
Material and Method
tribe was only 34.3% and from the in depth interview
conducted with the traditional leaders, the balian (the This analytic observational quantitative research
traditional spiritual leader/traditional healers) and other employed by a cross sectional design. The analysis unit
community members, the reason for this low uptake of was the household of Dayak Pitap tribe that had a 12 –
fully immunized children was probably because of the 35 month old child. Data collected from all households
community belief about the causes of illnesses which that had a 12 – 35 month old child in May to June 2018
are natural causes (heat, cold, rain), spirit of ancestor using a questionnaire. The respondent was the mother of
causes, shamanism causes, breaking taboos causes and 12 – 35 month old child.
other supra natural causes. This belief, therefore has an
implication on the initiatives that they use to prevent The independent variables were the mother’s
illness, namely always conducted aruh ritual, not violate education level, the mother knowledge about
papantang and the use of a samban for their children. immunization, the history of mother immunization
So besides the factors that have commonly stated as the status during pregnancy and the childbirth attendant
determinant factors of the immunization coverage, in the and the cultural determinant namely the aruh ritual, the
Dayak Pitap tribe, the cultural factor such as the aruh papantang and the use of samban, whereas dependent
ritual, the papantang and the samban probably also has variable was the child’s basic immunization status.
a contribution in determining the child immunization Data analysis using the univariable analysis to
coverage. describe the distribution of frequency and proportion
The aruh ritual is a ritual that conducted regularly of independent and dependent variables and logistic
by the Dayak Pitap tribe across the human life cycle and regression analysis to analyze the influence of
the rise cultivation cycle. The ritual filled with many independent variables toward the dependent variable.
kinds of sacred activities and materials, offerings and
also rhythm that accompany the spell of the mantra and Results
dance of the balian as the traditional spiritual leader. 1. Socio-demographic characteristics of
The absence of conducting the aruh ritual believed by respondent and children of Dayak Pitap tribe:
the community can cause misfortunes and illnesses. The majority of mother in Dayak Pitap were in 20
The papantang or taboo is a form of oral prohibition to – 29 years old interval (60%) and had primary
do something because it’s against the culture and educational level (42%) and 90% were farmer.
community tradition, although there was no legal or Their immunization
customary sanction for
knowledge level mostly was low (68%). Most of not complete their immunization during pregnancy
the mother had only one child (44%) with higher and 46% assisted by the traditional birth attendant
female distribution (54%). 66% of the mother did when delivered their babies.

2. Immunization Status of 12 – 35 month old child of Dayak Pitap tribe

Table 1: Immunization Status of 12 – 35 month old child of Dayak Pitap tribe

Number of Fully
Village Child 12 s/d 35 HB0 BCG DPT-HiB-HB Polio Measles Immunized
month old age Children
1 2 3 1 2 3 4 %
Ajung 23 14 19 18 14 11 22 15 13 11 13 8 34,8
Iyam 10 4 8 6 6 4 9 8 6 5 8 2 20,0
Kambiyain 9 9 9 9 8 8 9 9 8 8 9 8 88,9
Langkap 8 7 7 8 7 6 8 7 6 6 7 6 75,0
Total 50 34 43 41 35 29 48 39 33 30 37 24 48,0
3. Logistic Regression Analysis-Backward LR Method

Table 2: Result from Logistic Regression Analysis–Backward LR Method

Based on the table above, the dependent variables Pradesh, India (13) and most of tribal communities
that significantly influenced the independent variables worldwide especially for the children(14).
were the mother immunization knowledge level
(p=0.000), the history of mother immunization during Even if the using of samban significantly influenced
pregnancy (p=0.033), the history of birth attendant the child’s immunization status, the intervention of this
(p=0.00) and the using of samban by the children cultural variable is not easily formulated and need
(p=0.012). further research. Intervention with poor knowledge
about the culture itself can result in negative
consequences and can lead to worse health outcome.
Discussion
However, based on this research, health professional
The complete child immunization coverage in the known that the using of samban was significantly
Dayak Pitap tribe was 48%, still far from the Indonesian influenced the child’s immunization status of the
Heatlh Ministry target i.e. 92.5%. The highest coverage Dayak Pitap tribe.
was in Kambiyain village i.e. 88.9% and the lowest was
The history of mother immunization during
in Iyam village i.e. 20%. The highest immunization
pregnancy and birth attendant also significantly
dose coverage was Polio1 i.e. 48% and the lowest dose
influenced the child’s immunization status. These two
coverage was DPT-HiB-HB3 i.e. 29%.
variables actually correlated with the present of the care
Based on the data analysis conducted, the for pregnant women and labor that usually provided by
independent variables that significantly had influenced the midwife.
on the child immunization status of Dayak Pitap tribe As states by the WHO and other references,
were the mother immunization knowledge level, the immunization is one of the most successful and cost
history of mother immunization during pregnancy, the effective health intervention achievement, has saved
history of birth attendant and the cultural determinant countless of children’s lives and increased health status
namely the use of samban. Whereas the mother in the world (15)(16)(17)(18)(19)(20)(21). However, virus and
education level and the cultural determinant namely the bacteria do not respect border, if the disease still
aruh ritual and the papantang were not significantly circulate in any part of the world the risk of outbreak
influenced the child immunization status. still remained. In order to give all protection to all
children the high uptake of fully immunized children
Many research have shown that the mother
must be obtained all over the world and to reach the
immunization knowledge correlated with the child
under vaccinated, immunization programs need to
immunization status (5)(6)(7) and influenced the child
develop tailored intervention to overcome the
immunization (8)(9). Other research also shown that the
existing barriers.
mother with good immunization knowledge has 2.21
probability to fully immunized their children compare
Conclusions
with the mother with poor immunization knowledge (10).
The child immunization coverage of the Dayak
In this case, develop an intervention to increase the
Pitap tribe was 48%, lower than the Indonesian health
mother immunization knowledge with the combination
ministry target i.e. 92.5%. The determinant factor that
with the other interventions still promising in order to
significantly influenced the child’s immunization status
increase the fully immunized child coverage.
of the Dayak Pitap tribe were the mother immunization
The other determinant factor that significantly knowledge level, the history of mother immunization
influenced the child immunization status in the Dayak during pregnancy, the history of birth attendant and the
Pitap tribe was the use of samban. Using some kind of cultural determinant namely the use of samban.
amulet both for protection and curing not only known Hence, in order to gain the better child’s
in Dayak Pitap tribe but also widely known in many immunization status coverage of the Dayak Pitap tribe,
traditional cultures such as in Narsinghdi district in it is important to develop combination interventions to
Bangladesh (11), in Bedouin tribes of the Negev Southern give better knowledge about immunization to the mother
Israel, Middle East (12), in Gaddis of Bharmour Himachal with the tailor made material, promote birth attendant
labor and reach the pregnant mother for immunization.
Conflict of Interest: There is no conflict of interest for 2014;3(2):114-qq8.
all authors.

Source of Funding: This research funded by the authors

themselves. No other financial support received.

Ethical Clearance: All procedures performed in studies

involving human participants were in accordance
with the ethical standards of the Health Research
Ethics Committee Faculty of Public Health Airlangga
University.

Informed Consent: Informed consent was obtained

from all individual participants included in the study.

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DOI Number: 10.5958/0976-5506.2019.01683.8

The Use of Diuretic Drugs in Heart Failure Patients

Lolla Junny Avianda1, Didik Hasmono1, Meity Ardiana1, Ruddy Hartono1

1
Departement of Pharmacy, Faculty of Pharmacy, UniversitasAirlangga, Jl. Airlangga No.4 -
6, Airlangga, Gubeng, Kota SBY, JawaTimur 60115

ABSTRACT
Background: Heart failure can reduce the rates of expectations and quality of life. In the last few decades,
the management of this disease has developed continously, including in pharmacological therapy. Diuretic
is a class of drugs that is often used as a choice for heart failure patients. The pattern of diuretics usage
needs to be observed further. Because if the use of diuretics is not appropriate, it potentially leads to drug
related problems that affect patient management.
Objective: This study aims to examine the pattern of use of diuretics in heart failure patients who
are
undergoing treatment in hospital hospitalization units.
Method: This is a descriptive and retrospective study, using medical record data for heart failure patients
who received diuretic therapy in the patient room at the hospital. Sampling method used the time limited
sampling.
Result: Total patients who met the inclusion criteria were 50 patients, dominated by male (68%). The age
of patients, most of them were in the age group 61-70 years (32%). The most widely used diuretics were
the single dose furosemide (50%) and combination dose furosemide and spironolactone (36%). There was
no drug related problem (DRP) in the drug interactions and undesirable side effects.
Conclusion: Most diuretic therapies for heart failure patients who were hospitalized at the hospital, were
according to the available guidelines.

Keywords : heart failure, drug related problem,

diuretics
Introduction In general, it can be said that over the past 50
years, there have been three different eras related to the
Heart failure is a disease that increase a morbidity
management of heart failure. The earliest era, known as
and mortality rates. This disease weakens and reduces
the non-pharmacological era, focused in its treatment on
the expectations rates and quality of life. In this era,
fluid restriction. Then followed by the pharmacological
heart failure become an important health issue. Heart
era, that found an increasing use of inotropes and
failure results in 12 to 15 million outpatient visits per
diuretics and the discovery of vasodorators, and the
year. It becomes the most common reasons for
discovery of posterior drugs related to the
hospitalization in patients over the age of 65 years.
neurohormonal pathway. Along with all technological
Typical symptoms in heart failure are labored breathing
developments, new drugs are approved to improve
when the patient is in a rest and activity, fatigue, leg
significantly the prognosis of heart failure patients. In
edema. 1–3
addition, a new era also immediately gave rise to
regenerative therapy. 1,4-7
Correspondence Author: In pharmacological therapy, one of the choices
Didik Hasmono is using diuretic drugs. Diuretics are drugs that can
Departement of Pharmacy, Faculty of Pharmacy, increase urine flow rates, but clinically diuretics also
UniversitasAirlangga increase the excretion rates of Na+ (natriueresis) and
Jl. Airlangga No.4 - 6, Airlangga, Gubeng, Cl-, which is the accompanying anions. Diuretics have
Kota SBY, JawaTimur 60115 often been used as management of the heart failure
Email: [email protected] symptoms for many years. Because diuretics
interfere
852 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 852

a sodium retention by increasing urine sodium and free use of other drugs to determine drug interactions in heart
water clearance. The purpose of diuretics usage is to failure patients.
relieve the heart failure symptoms by reducing an excess
volume without causing intravascular volume depletion. The sample collection was done with the time
Diuretic classification is based on various ideas such limited sampling method. Data was collected in the
as workplace (loop diuretics), efficacy (high-ceilling medical medical record room at Hospital of
Bhayangkara H.S Samsoeri Mertojoso, Surabaya
diuretics), chemical structure (thiazide diuretics),
Indonesia. Data analysis was carried out based on data
similarity of work with other diuretics (thiazide-like
obtained from the patient’s medical record. Then the
diuretics), effects on potassium excretion (potassium-
data obtained from the data collection sheet was
sparing diuretics). 8–10
entered into the main table and then processed and
The most commonly diuretic that used for analyzed descriptively in the form of tables or
congestive heart failure is loop diuretics such as narratives.
furosemide which is given IV in doses of 40 mg,
followed by oral use if it takes 20-80 mg / 24 hours. This research had been reviewed by the Health
In most patients with loop diuretics can achieve Research Ethics Commission of Bhayangkara Hospital
sufficient diuresis to relieve congestive symptoms, but Surabaya and has been declared ethical.
when diuretic resistance arises, fluid management may
be complicated and potentially damaging. The pattern Results
of diuretic usage in heart failure patients still needs to
be studied more because of the possibility of improper Based on the results of the study, it was found 50
use of therapy and the potential of drug related problems patients who qualified the inclusion criteria and were
occur that affect the management of heart failure dominated by male sex (68%). Furthermore, most of
patients. 11–14 patients in the age group 61-70 years (32%). The most
complaints that patients had experienced were breathing
problems, chest pain and edema. In objective data, the
Method
diagnosis of heart failure was most evidenced through
The study that conducted was non-experimental or supporting data in the form of chest X-ray, ECHO and
observational research, that was a descriptive EKG. The history of the most comorbidities in heart
retrospective. The study material used health medical failure patients was hypertension (32%) followed
record data in patients with a diagnosis of heart failure by coronary heart disease, diabetes mellitus with
who received diuretic therapy in the hospital inpatient hypertension, and only diabetes mellitus.
room.
Patterns for Usage of Heart Failure Drugs
Specified sample inclusion criteria were patients
with heart failure and receiving diuretic therapy with or Profile of the use of heart failure drugs: The most
without complications. Furthermore, on the exclusion widely used drugs is the diuretic group, as many as 66
criteria, namely heart failure patients during the therapy frequency of use.
period, the patient died, or is referred to another hospital
and forced home. Table 1: Profile of the use of the group of
Research samples were recorded on the data heart failure drugs
collection sheet, including: patient profile (name, gender, Groups of drugs Frequency of usage
age, weight / height, address); date of hospital Cardiac Glycosides 5
admission, date of hospital discharge, and medical
ACE Inhibitor 18
record number; diagnostics, laboratory data, and kinetic
data; Disease history, treatment history, and complaints ARB 16
experienced; The variables of diuretics that given to Β Blocker 26
patients include type, dosage, and route of Diuretics 66
administration. Nitric 28
Data analysis was done by calculating the number Note: *) One patient can receive more than
of patients and grouping patients based on patient one
demographics, types of diuretics used and complications medication for heart failure during treatment
or comorbidities. In addition, it is necessary to know the
Type of Diuretics: The highest usage of diuretic drugs hydrochlorothiazide and furosemid, and combination
is furosemid with 50% a combination of furosemide and of hydrochlorothiazide and spironolactone, which their
spironolactone (36%). And the the following type of values are 36%, 10%, 2% dan 2%.
diuretics mostly used are
Dosage of Diuretics: The use of diuretic doses is
The highest use of diuretic drugs is furosemide divided into the use of single doses and combination
(50%), then followed by a combination of furosemide doses which will be presented in detail in the table
and spironolactone, spironolactone, combination below.

Table 2: Single dose of diuretics

Type of diuretics Dose regimentation Frequency
Furosemide 2,5mg/ hour pump 2
10mg/hour pump 9
1x20mg IV 1
2x20mg IV 4
3x20mg IV 1
1/2x40mg p.o 1
1x40mg p.o 7
1/2x25mg p.o 1
Spironolactone
1x25mg p.o 4

Table 3: Dosage of diuretic combination

Regimentasi dosis
Frequency
Furosemide Spironolactone Hydrochlorothiazide
1/2x100mg p.o - 2
1x100mg p.o - 1
5mg/hour pump
2x25mg p.o - 1
- 2x25mg 1
10mg/hour Pump 1x25mg p.o - 3
1x20mg IV 1x25mg p.o - 2
2x20mg IV 1x25mg p.o - 1
2x25mg p.o - 1
3x20mg IV
1x25mg p.o - 1
1x40mg p.o 1x25mg p.o - 3
2x40mg p.o 1x25mg p.o - 3
- 1x25mg p.o 1x25mg p.o 1

Diuretics Route: The most therapeutic route of diuretics is oral.

Table 4: Diuretics route

Diuretics route Frequency Percentage (%)

Intravenous pump 19 27
Furosemide Intravenous 11 16
Per oral 14 20
Conted…
Spironolactone Per oral 24 34
Hydrochlorothiazide Per oral 2 3

Note: *) The number of routes given above is not the same as 50 patients, because in one patient can
get a single diuretic therapy or combination diuretic therapy
Diuretic Therapy Monitoring: Monitoring of diuretic therapy is conducted with electronic serum monitoring.

Table 5: Diuretic Therapy Monitoring

Patients using diuretic therapy Frequency Percentage (%)
Serum electrolyte monitoring was carried out 29 58
Serum electrolyte monitoring was not carried out 21 42

Identification of Drug Related Problem (DRP)

Drugs Interaction: The percentage of possible drug interactions in heart failure patients is not equal to
100%
because not all patients experience potential drug interactions.

Table 6: Drugs Interaction

Type of Drugs Interacted with Mechanisms of Drugs Interaction Frequency Percentage (%)
Amiodaron Causes an increase in ventricular arrhythmias 3 6
Furosemide
Digoxin Increases digoxin toxicity 5 10
Potassium chloride Causes hyperchalemia 3 6
Spironolactone
ACE Inhibitor Causes hyperchalemia 2 4
In the use of furosemide with digoxin monitoring, that depend on the body, such as the ankle (Edema
therapy of furosemide with digoxin was monitored more pedal) for outpatients or sacred areas to sleep in the
than 4 patients (80%) rather than those who were not patient’s bed. Bowel or stomach blockages can also
monitored as many as 1 patient (20%). And then heart appear, but it does not lead to characteristic signs unless
failure patients who used spironolactone therapy with proven to be open ascites. In right ventricular failure it is
ACE-I contained 2 patients with 1 patient who did not also possible to find the pulmonary hypertension. 15
carry out serum electrolyte monitoring (50%).
The status of heart failure can be seen from medical
Side effects of drugs: In this study was found no support data such as echo, chest X-ray and ECG. The
drug medical support data above is related to completing
side effects occurred in heart failure patients. the diagnosis of heart failure, where ecocardigraphy
is the most useful method in evaluating systolic and
Discussion diastolic dysfunction. Chest X-ray is also an important
component in diagnosing heart failure such as showing
From the data shows the heart failure patients who cardiomegaly. An electrocardiogram should be
were undergoing hospitalization, complaints a shortness performed on all patients suspected of heart failure.
16

of breath and chest pain. Dyspnea or shortness of

From the results study above, patients who were
breath can result in pulmonary blockage or systemic
diagnosed with heart failure were in the age range 61-
hypoperfusion due to left ventricular failure. Patients
70 years. The diagnosis of heart failure manifests most
usually experience various symptoms that associated
commonly in adults that over 60 years. The incidence of
with systemic fluid accumlation which are known to heart failure increases with age, and reaches 1% per year
be venous blockages, associated with right ventricular in people over 65 years old. 15,17
failure ie peripheral edema. This usually occurs in areas
The most common history of comorbidities in Other potential interactions was a combination of
heart failure patients is hypertension. One factor that furosemide with digoxin. Cardiac glycosides inhibit
contributes to the development of primary hypertension sodium and potassium ATP-ase, which is associated
is a physical disorder involving the renin-angiotype- with the transport of sodium ions and potassium ions
aldosterone system (RAAS) and natriuretic hormone. acrossing the myocardial cell membrane. This is related
Furthermore, the second most common comorbid to an increase in the availability of calcium ions that
disease is diabetes mellitus. Changes in structure that associated with contractions from cells. The loss of
show a concentric left ventricular remodeling as a calcium is caused by diuretics, exacerbates potassium
characteristic of diabetes.. 15
loss from myocardial cells, thereby increasing the
The results showed the classification of drugs used activity and toxicity of digitalis. 20
in heart failure patients that mostly consumed, is a
Other potential drug interactions occur between
diuretic. Other classes of heart failure drugs used are
spironolactone and KSR. The effects of spironolactone
glycosides, ACE inhibitors, ARB groups, β inhibitors
and potassium compounds are additives, which can
and nitrate groups. The diuretic drugs used are
cause hypercalemia. In addition, spironolactone and
hydrochlorothiazide (thiazide diuretic), furosemide (loop
ACE inhibitor groups also has the potential to cause
diuretic), and spironolactone (potassium-sparing
reactions. ACE inhibitors can inhibit aldosterone
diuretic). These uses are either single or combination
which results in potassium retention, so it is expected
doses. In this study, the single dose of furosemide
was given due to its higher diuresis and natriuresis to maintain adosterone potassium antagonists, such
efficiency. Whereas, the combination of furosemide and as spironolactone which causes hypercalemia. 20 In
spironolactone is given because potassium-sparing many patients that use combination therapy, the serum
diuretics are weak diuretics when used singly but it electrolyte was monitored. However, in this study was
cause potassium retention, so they are usually given with found no actual drug interactions. Furthermore, on the
loop diuretics to prevent hypokalaemia. 16,18,19 issue of other potential drug interactions is drugs side
effects. In this study there were not found a patient that
The loop diuretic is a diuretic group which has the experienced the diuretic side effects.
same ability to block the symporter Na+ -K+ - 2Cl- in the
raised portion of the Henle loop diuretic. This drug is
Conclusion
given orally to reduce peripheral edema and pulmonary
edema in moderate to severe stage of heart failure. Loop Most of the usage of diuretic therapy in heart failure
diuretics are effective in patients with reduced kidney. patients in inpatient installations, had been in accordance
18.20
with existing guidelines. In this study, there was no
In the administration route of furosemide in Drug Related Problem (DRP) of diuretics usage.
heart failure patients is more given by pump than by Conflict of Interest: There is no conflict of interest
intravenous or per oral method. Continuous intravenous in
administration of furosemide is indeed simpler, more this study
effective, and a method to accelerate diuresis in certain
patients. The administration of furosemide to patients Source of Funding: This research was carried out by a
depends on the clinical symptoms of the patient.21 team and funded independently

Problems that related to the use of potential diuretic

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ackd.2018.08.007
DOI Number: 10.5958/0976-5506.2019.01684.X

The Antibacterial Activity of Kersen Leaves (Muntingia

Calabura)
Extracts against Aeromonas Hydrophilia; in Vitro
Study

Onny Kurnia Sari1, Wahyu Tjahjaningsih1, Sudarno1

1
Faculty of Marine and Fisheries, Universitas Airlangga, Dharmahusada Permai No.330 street,
Mulyorejo, Surabaya, East Java (60115), Indonesia

ABSTRACT
Background: Aeromonas hydrophila is one of opportunistic bacteria that capable causing disease in fresh
water fishes. The outbreak of diseases in fresh water fishes become an important issue in fish farming.
Antibiotics can be used as therapy for those problems. But the usage of antibiotics can cause the bacterial
resistance and side effects of medications. The usage of antibiotics in fish farming also can trigger the water
polution.
Objective: The aim of this study was to observe the antibacterial activity of kersen leaves Muntingia
calabura extracts against A. hydrophila with in vitro study and to determine the minimum concentration the
extracts that inhibit the bacterial growth and its ability to kill the bacteria.
Method: There was nine group consisted the extracts with various concentration, as 50%, 25%,
12,5%,
6,25%, 3,12%, 1,56%, 0,78%, positive control group with chloramphenicol, and negative control group
with
dimethyl sulfoxide (DMSO) 10%. Those extract was soaked in bacterial culture and incubated for 24
hours.
Result: The young kersen leaves extracts had stronger antibacterial activity against A. hydrophila,
compared
to the old kersen leaves. Minimum Inhibition Concentration (MIC) of the extracts was at concentration of
50% and Minimum Bactericidal Concentration (MBC) was at concentration of 12,5%.
Conclusion: Kersen leaves extract has antibacterial activity against A. Hydrophila by in vitro study.

Keywords: Aeromonas hydrophilia, Muntingia calabura, leaves extract, fish

farming
Introduction Aeromonas Septicemia (MAS). The symptoms of this
disease are ulceration, erythrodermatitis, hemorrhagic
Outbreak of disease is one of the obstacles that
septicemia, red disease, and prominent scales (1).
often occur in fish farming. Aeromonas hydrophila is an
opportunistic bacterium, the cause of disease in various One of the natural products that can be utilizded
types of freshwater fish. These bacteria attack the as natural medicine is kersen. Kersen is a small fruit,
internal organs of the fish through the digestive tract or that well known and healthy, produced from trees that
the skin of fish that have not been injured. This occurs have many benefit (2). Kersen plant is easily found on the
because the fish are stressed due to density or increase in roadside as shades and it has good ability in adaptation.
extreme environmental temperatures. The bacterial Kersen leaves contain various bioactive compounds,
infection, that caused by A. hydrophila, is better such as flavonoid, saponins, triterpenes, and tannins
known as Motil (3)
. The study by Fariestha (2018) shows the methanol
extract of kersen leaves had antibacterial activity against
gram positive bacteria, that is Staphylococcus aureus (4).
Corresponding Author: Faculty of Marine and Fisheries, Universitas Airlangga,
Wahyu Tjahjaningsih
2Dharmahusada Permai No.330 street, Mulyorejo,
Surabaya, East Java (60115), Indonesia Based on some statements above, the antibacterial
activity of kersen leaves extracts were tested to observe
Phone: (031) 591145
its ability to inhibit the growth and kill gram negative
Email: [email protected]
bacteria, A. hydrophila, which can threaten the success
of fish farming. The experiment was done by extracting
the leaves of kersen, then followed by doing an
antibacterial activity test with the disk diffusion test and
858 Indian Journal of Public Health Research
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& Development, July 2019, Vol.10, No. 7 858

streak method to determine the antibacterial activity A. hydrophila and has strong efficacy in inhibiting
of the
kersen leaves extract to A. hydrophila. growth of A. hydrophila (7).

Minimum Inhibitory Concentration (MIC) with

Materials and Method difusion methods: Before the Minimum Inhibitory
Equipment: The equipment that used in this experiment Concentration (MIC) test of kersen leaves extract was
such as blender, digital scales, oven, reaction flasks, done, the preliminary experiment was carried out to
rotary vacuum evaorator, autoclave, test tubes, tube determine efficacy of young and old kersen leaves
rack, measuring pipette, petri dish, bunsen burner, Ose extract against A.hydrophila (4). The efficacy test of
needle, micropipette, glass stirrer, laboratory tweezer, antibacterial activity carried out using disk diffusion
and ruler. test. The extract that used in prelimenary experiment
was kersen leaves extract with concentration 100%.
Materials: The materials in this study were pure isolates
of Aeromonas hydrophila, that obtained from the Juanda
Quarantine Hall, Surabaya, young kersen leaves (that
the leaves color is light green), old kersen leaves (that
the leaves color is dark green), methanol, Whatman
filter No. 1, aquadest, dimethylsulfoxide (DMSO) 10%,
barium chloride (BaCI) 1%, sulfuric acid (H SO )
1%, 2 4
physiological saline (NaCl), chloramphenicol, Whatman
disk paper No.42, trypticase soya agar (TSA).

Preparation of Mc Farland 0,5 (1,5x108 sel/ml) Figure 1: The efficacy test of antibacterial activity of
solution: Mc Farland solution preparation was done by young and old kersen leaves extract. Explanation:
mixing 0.05 ml of barium chloride (BaCl2 ) 1% and 9.95 Arrow sign = inhibitory zone
ml of sulfuric acid (H2 SO4 ) 1% in a test tube. Then it was
shaken until a turbid solution formed. This turbidity 2 ml solution from the test tube 0.78% was taken and
is discarded because it was not used (6). The positive
used as the standard turbidity of bacterial suspension control group was using 2 ml of chloramphenicol, while
tests a negative control group was using 2 ml of DMSO 10%.
Chloramphenicol is often used for the treatment against
Kersen leaves extract preparation: Kersen leaves
extract was diluted with dimethyl sulfoxide (DMSO)
solvent 10%. DMSO solution functions as a solvent
that quickly seeped into the epithelial extract without
damaging the cells. DMSO solution is often used in the
medical and health research (5).

Before the test tube was being used, it was labeled

according to the concentration of the solution. The
concentration of the solution were 50%, 25%,
12.5%,
6.25%, 3.12%, 1.56%, 0.78%. The preparation of
solution with concentration 50% was done by mixing 4
grams of kersen leaves extract with 4 ml DMSO 10% in
the test tube, stirred with a glass stirrer until
homogeneous. For the solution with concentration 25%
was carried out by mixing 2 ml of solution with
concentration 50% and 2 ml DMSO 10%, then stirred
until homogeneous.

The preparation of the other solution with lower

concentration was done by mixing 2 ml of the solution
from the previous test tube and 2 ml of DMSO 10%.
After the last concentration of 0.78% was obtained,
a
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 859
Minimum Inhibitory Concentration (MIC) with disk
difusion methods: The paper disks were soaked in
kersen leaves extracts with various concentrations. After
± 15 minutes, paper disks were taken aseptically
using
laboratory tweezers, then aerated in room
temperature
± 3 minutes until dried. Paper disks were placed and
slightly pressed onto the surface of the bacterial media
(one medium was given one disk paper). All tested
media were incubated at 28º C for 24 hours and the
inhibitory zones were measured using a ruler. The
minimum inhibitory concentration (MIC) was measured
by subtracting the overall diameter of the paper disks
and inhibitory zones with the diameter of the disk
paper(8).

Minimum Bactericidal Concentration with Streak

Method: Minimum Bactericidal Concentration (MBC)
with streak method was carried out to determine the
bactericidal ability of kersen leaves extract. The test
was carried out by adding 1 ml of liquid isolate of A.
hydrophila with a density of 107 cells/ml into each
extract solution and the control group, then it was
homogenized. The mixture of bacteria colony and the
solution was taken using Ose needle and streaked to
TSA plates, then incubated at 28ºC for 24 hours. If the
bacteria was occurred in TSA plates, it shows that the
extract solution did not have ability to kill the bacteria.
If there is no presence of bacteria in TSA plated, it
shows the extract solution had ability to kill bacteria (9).
Results The young kersen leaves extract at concentration
of 0.78% shows no inhibition zone was seen. That was
Table 1: Minimum Inhibitory Concentration (MIC) meant the extract with concentration of 0.78% could not
of Kersen leaves extract inhibit the growth of A. hydrophila. The antibacterial
activity of young kersen leaves extract was seen at
Diameter of concentration of 1.56%, characterized by the presence
Concentration of young Kersen
No. inhibitory of inhibitory zones around the disk paper. The higher
leaves extract
zone (mm)
concentration of young kersen leaves extract, the larger
1. 0,78% 0 the inhibitory zone that appeared around the disk paper
2. 1,56% 2 (10)
. Chloramphenicol was used as a positive control,
3. 3,12% 5 while the negative control using DMSO 10%. In positive
4. 6,25% 6 control group shows a very large inhibitory zone that
5. 12,5% 9 was 20 mm, while the negative control group did not
6. 25% 14 show any antibacterial activity, so there was not found
7. 50% 15 any visible inhibitory zone around the disk paper. The
results shows that the minimum inhibitory concentration
8. Positive control (chloramphenicol) 20
of young kersen leaves extract that approaching positive
9. Negative control (DMSO 10%) 0
control was the extract at concentration 50%.

0,78% 1,56% 3,12% 6,25%

12,5% 25% 50%

Figure 2: Minimum Bactericidal Concentration (MBC) of young kersen leaves extract. Explanation : Arrow
sign = A. hydrophila bacterial colony
Figure 2 shows the growth of A. hydrophila is gram-negative and rod-shaped bacteria. A. hydrophila
is indicated by an arrow sign. In TSA plate with a was gram negative bacteria, facultative anaerobes,
concentration of 12.5%, 25%, and 50%, there was no rod shaped in 0.3-1.0 x 1.0-3.5 µm which moved with
bacterial growth. That shows at these concentration flagellum, had fermentative oxidative characteristic (12).
young kersen leaves extracts had ability to kill bacteria. Catalase, H S, indole, β-galactosidase, oxidation occurs,
2
It can be concluded, the minimum concentration of but not on ornithin, decarboxylase and or phenylalanine,
young kersen leave extract which can kill A. hydrophila deaminase. There was a positive result, but it did not
is 12.5% (11). occur in the methyl red test(13). In bacteria culture was
done, the bacterial colonies on the media appeared
Discussion creamy on agar media.

The results of this study shows that the bacteria Table 1 shows the higher of concentration of kersen
that the identified bacteria are A. hydrophila (Table 1). leaves extract, the greater its ability to inhibit bacteria
In Figure 1, reddish-colored bacteria shows the bacteria growth. The positive control group used
chloramphenicol
treatment, because it is often used for the treatment Conclusion
of infection caused by A. hydrophila and very strong
inhibits the growth of A. hydrophila (13). The negative The kersen leaves extract had antibacterial activity
control group used DMSO, because its properties are against A. hydrophila, by in vitro study. The minimum
neutral and does not damage cells (5). inhibitory concentration of kersen leaves extract that
approaching the positive control group was 50%, with a
Raho and Benali (2012) states in their research that 15 mm of diameter inhibitory zone, in 24 hours
the provisions that indicate the antibacterial strength of incubation period. The minimum bactericidal
chloramphenicol as followed the inhibitory zone <12 concentration of kersen leaves extract against A.
mm indicated weak, 13-17 mm indicated medium, hydrophila bacteria was
and 12.5% in 24 hours incubation period.
> 18 mm indicates as very strong (11). The results in
this study shows the chloramphenicol had antibacterial Ethical Clearance: The research process did not
strength that very strong, it resulted in 20 mm of involve any participants for object, instead only use
diameter inhibitory zone. Whereas the MIC test results diffusion method with kersen leaves and aeromonas
bacteria. The process of research has been following
of kersen leaves extract when compared to
principle based on the regulation of research ethic
chloramphenicol were included in medium categoriy, it
committee. This study implemented the basic principle
resulted in 15 mm of diameter inhibitory zone. Young
ethics of respect, beneficence, nonmaleficence, and
kersen leaves extract at the concentration of 0.78%
justice.
shows no inhibitory zone, because the concentration was
very low, so it was not able to inhibit the growth of A. Conflict of Interest: The author reports no conflict
hydrophila (14). of
interest of this work.
The content of flavonoids on the extracts resulted in
inhibition bacterial growth. The action of flavonoids as Source of Funding: This study is done with
antibacterial is by releasing transduction energy towards author’s
the cytoplasmic membrane of bacteria and inhibiting funding only,
bacterial motility. In addition, tannin compounds
also play a role in inhibiting bacterial growth. Tannin REFERENCE
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DOI Number: 10.5958/0976-5506.2019.01685.1

Could the Severity of Infected Gingiva in Pregnant Woman

Affect the Quality of Life?

R. Darmawan Setijanto1, Novia Setyowati1, Taufan Bramantoro1, Achmad Aghasy1

1
Departement of Dental Public Health, Faculty of Dental Medicine, Universitas Airlangga, Surabaya,
Indonesia

ABSTRACT
Background: Observation carried out in early 2016 to a number of pregnant women in Community Health
Center Surabaya found that more than 80% of pregnant women had infected gingiva or gingivitis. Pregnant
women are susceptible to oral and dental disease. Oral heath problem could impact on oral health-related
quality of life, includes physical pain, physical disability, psychological discomfort, functional limitation,
and social disability.
Objective: The aim of this study was to analyze the influence of severity level of infected gingiva on oral
health-related quality of life of pregnant woman.
Method: A cross-sectional study was conducted in 10 Community Health Centers Surabaya and involved
106 pregnant women. All of participants were examined regarding their severity level of infected gingiva,
also answered the quality of life questionnaire.
Result: Lower quality life of pregnant woman were observed in woman presenting more severe
infected
gingiva level.
Conclusion: Oral health-related quality of life of pregnant woman were influenced by the severity level of
infected gingiva.
Keywords: gingivitis, pregnancy, quality of life,
woman
Introduction Phone: (+62 31) 5030255, 5020256
Email: [email protected]
Pregnant women have higher prevalence of
gingivitis
than non-pregnant women1. Pregnancy gingivitis affects
25-100% of pregnant women and occurs during 2nd
to
8th month of pregnancy2. Indonesian Dental Association
has recorded prevalence of pregnancy gingivitis 75-90%
worldwide, meanwhile in Indonesia it is up to 5-10% 3,4.
In early 2016, initial survey upon pregnant women
conducted at Community Health Center Surabaya found
that more than 80% pregnant women had gingivitis.

Corresponding Author:
Taufan Bramantoro
Department of Dental Public Health,
Faculty of Dental Medicine, Universitas Airlangga
Jalan Prof. Dr. Moestopo 47, 60132, Surabaya,
Indonesia
During pregnancy, progesteron level in body could
be
10 fold higher than normal level. This kind of condition
potentially increases certain pathogenic bacteria growth
that lead to gingivitis5.

There are several factors which could influence

susceptibility of pregnant woman to gingivitis, such as
gestational age, nutritional status and the presence of
systemic disease i.e diabetes mellitus. Gestational age
is associated with susceptibility of pregnancy gingivitis
because of hormonal change such as an increase of
estrogen and progesterone as gestational age increases6.
Poor nutritional status of pregnant woman could
decrease immunity against various diseases, particularly
infectious disease. Malnutrition or poor nutritional
status has synergistic relationship with infection, which
means malnutrition deteriorates infectious disease, and
infection deteriorates malnutrition7. Any changes in
immune system and estrogen and progesterone level
in 40% of pregnant women lead to gingivitis during
pregnancy5,8,9.
863 Indian Journal of Public Health Research
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& Development, July 2019, Vol.10, No. 7 863

Chronically and untreated pregnancy gingivitis gingivitis before pregnancy. (3) with systemic disease, i.e
could increase risk of premature birth and low birth diabetes mellitus. (4) irregular high-fiber containing food
weight (LBW) 10. This is emphasized by National Health (vegetables and fruits) consumption.
Survey 2002 which showed that 77% of pregnant
women with gingivitis have preterm labor. In addition, This study employeed questionnaire form as
in a study reported by Retroningrum 2006 carried out in instrument to know respondents data and Oral Health
Kariadi Hospital Semarang showed that pregnancy Impact Profile (OHIP-14). Also, gingival index form to
gingivitis had risk factor of low birth weight (LBW) as assess severity level of gingivitis. Oral Health Impact
8,75 times higher than those without gingivitis11. Profile (OHIP-14) questionnaire form have been modified
spesifically to know level of oral health-related quality of
Gingivitis as oral health problem frequently life of pregnant woman. Before questionnaire
occurs during pregnancy could impact on individual modification, translation of instrument had been done
well-being such as physical pain, physical limitation first. After translating instrument of oral health-related
and psychological discomfort. Impact of oral health quality of life of pregnant woman, researcher did validity
condition on quality of life is evaluated and defined as and reliability test. During validity and reliability test,
Oral Health-Related Quality of Life (OHRQoL). United questionnaire instrument was distributed with cluster
States Surgeon General’s report defined oral health- random sampling to pregnant women in Maternal and
related quality of life as a multidimensional concept Child Health (MCH) Clinic, Community Health Center
that describe oral health–related comfort during eating, Surabaya.
sleeping and involving in social interaction. Acharya
et al stated that periodontal disease in pregnant woman Questions in questionnaire of oral health-quality of
lead to poor oral health-related quality of life .
12 life consisted of 7 dimensions, as follows: 1. Dimension
of functional limitation; 2. Dimension of physical
According to previous study, it has been found pain;
impact of gingivitis during pregnancy on oral health- 3. Psychological discomfort; 4. Physical disability; 5.
related quality of life, but the lack of available data Psychological disability; 6. Social disability; 7. Handicap.
about that in Indonesia is the underlying reason to In that questionnaire, respondent would be asked how
investigate correlation between severity level of frequent they had gum impairment during pregnancy using
pregnancy gingivitis and oral health-related quality of Likert scale. The choices of answer of questions in oral
life of pregnant woman. health- related quality of life of pregnant woman
questionnaire were “very often”, “fairly often”,
Material and Method “sometimes”, and “vever” with score as 1, 2, 3, and 4,
respectively. The higher the score, the better the quality of
This study was analytical observational quantitative life.
study with cross sectional study design, aiming to
investigate correlation between risk factors and effect. Selected pregnant women were given informed
The samples were chosen using cluster random sampling consent as their approval to participate as study sample.
method, resulting of 106 pregnant women as After that, intraoral examination was done using
respondents in 10 Community Health Center Surabaya. periodontal probe and mouth mirror to see the severity
All the procedures in this study were conducted level of gingivitis in respondents, and recorded on
according to the approval of Ethical Commission. gingival index. This study received ethical approval
from Ethics Committee Faculty of Dental Medicine,
This study had inclusion and exclusion criteria. Universitas Airlangga. For analysis, distribution table
Inclusion criteria included: (1) pregnant woman without was used with percentage as confirmation. Present
dental calculus; (2) never have gingivitis before study employeed correlation test to analyze correlation
pregnancy; (3) without systematic disease, such as between pregnancy gingivitis and oral health-related
diabetes mellitus; (4) pregnant woman on early first quality of life of pregnant woman.
trimester, late first trimester, early second trimester, late
second trimester, early third trimester, and late third
RESULT
trimester; (5) regularly consuming high-fiber
containing food (vegetables and fruits). Exclusion In this study, characteristics of pregnant women in
criteria of study included: (1) pregnant woman with Community Health Center Surabaya had been known,
dental calculus; (2) with history of
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& Development, July 2019, Vol.10, No. 7 864
such as: age, level of education, employement status,
monthly income, gestational age and maternal mid-
upper arm circumference (MUAC). In terms of age, of total respondents), and mean MUAC was 28 cm.
mean age of pregnant woman was 28 years, most of It showed that most pregnant women in Community
them aged 24-32 years (59.5%). Majority of respondents Health Surabaya had good nutritional status.
had ever attended level of education minimum Senior
High School (67.9%). Most of them (68.9%) were Oral hygiene level of pregnant women (68.9%
unemployeed. Monthly income of respondents was of total respondents) was classified as moderate with
under five million rupiahs (97.2%). Most respondents mean score by 2.4. Also, 47.2% of total respondents had
examined in Community Health Center belonged to moderate severity level of gingivitis, and mean score
low and moderate economic class, and 50.9% had third of gingival index was 1.3. Moderate level of gingivitis
trimester of gestational age with mean age possibly could decrease oral health-related quality of life
approximately of pregnant woman, thus results in low OHIP-14 score.
24 years. Majority of MUAC were 23.5 cm (88.7%

Table 1: Value of correlation coefficient and significance level of pregnancy gingivitis on each item of Oral
Health Impact Profile-14
Dimension Item Correlation coefficient (r) Significance level (p)
Functional Difficulty in pronouncing any words - 0.047 0.631
limitation Sense of taste impairment - 0.226* 0.020
Painful aching on gum - 0.187 0.055
Physical pain
uncomfortable to eat any foods - 0.134 0.171
Psychological Feeling self conscious - 0.175 0.073
discomfort Feeling tense - 0.082 0.405
Unsatisfactory diet - 0.199* 0.041
Physical disability
Interrupted meal - 0.283* 0.003
Psychological Difficult to relax - 0.253* 0.009
disability A bit embarrassed - 0.078 0.428
Social disability Difficulty in doing usual jobs - 0.197* 0.043
Handicap Totally unable to function - 0.167 0.086
Tabel 2: Value of correlation coefficient and Discussion
significance level of pregnancy severity on oral
health-related quality of life of pregnant woman As presented on study result, the severity level of
pregnancy gingivitis in Surabaya according to Loe &
Correlation Significance
Variable Silness gingival index was moderate, and oral hygiene
coefficient (r) level (p)
status was classified as moderate. On third trimester of
Quality of life
- 0.327* 0.001 pregnancy, estrogen and progesterone level increases,
score (OHIP-14)
thus vascularization and blood vessel permeability
Table 1 shows that there is correlation between of gingiva is also increased13. The presence of debris
severity level of pregnancy gingivitis and oral health- and calculus is overresponded by gingiva that leads to
related quality of life of pregnant woman particularly in gingival inflamation, redness and easily bleeding. It
dimension of functional limitation, physical disability, shows that hormonal factor could worsen plaque
psychological disability, and social disability.
bacteria as local factor14.
Table 2 shows that there is significant correlation
Pregnancy gingivitis is one of oral diseases that
between severity level of pregnancy gingivitis and oral
frequently affects pregnant woman particularly on 2nd to
health-related quality of life of pregnant woman. This is th
8 month of pregnancy2. This is confirmed by present
negative correlation which means the higher the severity
study result that demonstrated 54 of 106 pregnant
level of gingivitis, the lower the quality of life, and vice
woman had gingivitis on third trimester of pregnancy.
versa.
Pregnancy
gingivitis could present some clinical manifestations function keep maintained, thus nutrition intake, dental
which may influence daily activities and quality of life15. and overall health of pregnant woman are maintained in
One of instruments used to assess oral health-related good condition20.
quality of life is Oral Health Impact Profile 14
(OHIP Dimension of psychological disability includes
– 14). OHIP – 14 is a multidimensional concept which being difficult to relax, which means the higher the
describes comfort during eating, sleeping, and socially severity level of pregnancy gingivitis, the more difficult
interacting16. According to the present study result, mean pregnant woman relaxed. Bleeding gingiva is one of
score of oral health-related quality of life of pregnant discomfort that commonly occur during pregnancy. This
woman in Community Health Center Surabaya was condition is normal and not life-threatening, but for most
fairly good. of pregnant women it may cause anxiety so that they are
difficult to relax21. Gingival enlargement particularly in
The presence of oral health impairment may impact anterior region as clinical manifestation of gingivitis
significantly on physical, psychological and social well- may also impact on psychological aspect22. Gingival
being, thus influences quality of life. Impairment in oral problems will impact on communication process
cavity such as periodontal disease e.g life-threatening because oral structure is the important part of verbal and
impairment on gingiva may contribute to preterm birth non-verbal communication, hence it may influence self
and low birth weight, influence respiratory disease, image and ability to survive and build social relation17.
gastrointestinal, stress and decrease immune system
againts infection17,18. The presence of gingival problems Dimension of social disability includes difficulty
may lead to stress, therefore it could make patient afraid, to do usual jobs, which means the higher the severity
anxious, having painful aching and discomfort. If it is level of pregnancy gingivitis, the more difficult pregnant
untreated, quality of life will be influenced17. woman to do usual jobs. Gingival problems may cause
pain and discomfort during activities, thus it could
In this study, the severity level of pregnancy decrease work productivity17. The severity level of
gingivitis had influence on quality of life particularly pregnancy gingivitis has significant correlation with
in dimension of functional limitation, physical oral health-related quality of life of pregnant woman.
disability, psychological disability, dan social disability. Therefore, if the severity level of pregnancy gingivitis
Dimension of functional lmitation includes sense of is high, oral health-related quality of life of pregnant
taste impairment, thus appetite is decreased. Decreased woman will be low, and vice versa.
appetite will infuence intake of vitamin A and fiber
which is highly required by pregnant women, Conclusion
particularly fruits and vegetables, consequently in
addition to promote gastrointestinal disorder, of course it Based on study result and discussion, it has been
will impact on comprehensively maternal and fetal known that there is negative correlation between the
health17. severity level of pregnancy gingivitis and oral health-
related quality of life of pregnant woman, which means
Dimension of physical disability includes the higher the severity level of gingivitis, the lower the
discomfort in eating any foods, which means the higher quality of life and vice versa.
the severity level of pregnancy gingivitis, the more
uncomfortable in eating any foods, and vice versa. Conflict of Interest: No potential conflict of
Beside physical disability, severity level of pregnancy interest
gingivitis also impact on meal process, which could was reported by the authors.
lead to interrupted meals. It shows that the higher the
Source of Funding: The current research did not
severity level of pregnancy gingivitis, the more frequent
receive any specific grant from funding agencies in the
they have interrupted meals. Impairment in dimension
public, commercial, or not-for-profit sectors.
of functional limitation and physical disability is caused
by clinical manifestation of pregnancy gingivitis such Ethical Clearance: All the procedures in this study
as gingival enlargement on papilla of one or two teeth were conducted according to the approval of Ethical
that may interfere mastication19. It is crucial for pregnant Commission.
woman to maintain oral health in order to
masticatory
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DOI Number: 10.5958/0976-5506.2019.01686.3

Age and Education Distribution Patterns of Working Mothers

on Dental Health Behavior in Preschool Children in
Mid-Class Society

Isnawati1, R. Darmawan Setijanto2, Taufan Bramantoro2, Dinda Dewi Zalinda3

1
Master Program in Dental Health, Faculty of Dental Medicine, Universitas Airlangga, 2Department
of Dental Public Health, Faculty of Dental Medicine, Universitas Airlangga; 3Department of Health,
Vocational Faculty, Universitas Airlangga

ABSTRACT
Background: Dental caries is a common disease in children which if left untreated, it may affect weight,
growth and the quality of life in childhood. The behavior of parents, especially mothers, affects the
children’s oral health, because mothers aside of being the decision maker for the children, they also have
careers.
Objective: This study aimed to analyze the relationship between age and education of working mothers on
dental health behaviors in pre-schooled children aged 5-6 years.
Method: This was a cross-sectional study, involving working mothers who have children aged 5-6 years in
Banjarbaru, South Kalimantan. The number of respondents was 101 working caregivers, that was chosen by
means of a cluster random sampling technique. The data were obtained through interview and
questionnaire. The results were analyzed statistically using logistic regression test with a significance value
of p<0.05.
Results: There was no significant relationship between age and education of working mothers on
dental
health behaviors in preschoolers.
Conclusion: The age and education of working mothers are not related to dental health behavior in
preschool
children in Banjarbaru South Kalimantan.
Keywords: age, education, mother behavior
Introduction oral health problems was found in South Kalimantan
Province (36.1%), making it the second highest after
The World Health Organization (WHO) stated
South Sulawesi (36.2%)3. Previous research, analyzing
that
the relationship of dental caries with the quality of life
60-90% of school children worldwide suffered from
in school children aged 5-7 years in Landasan Ulin
caries1, a common disease which if untreated, it may
Sub-district, Banjarbaru, South Kalimantan proved
affect weight, growth, and quality of life, especially
the average of primary tooth suffering dental caries as
in childhood2. Basic Health Research in 2013 stated
that dental and oral health in Indonesia remained many as 9 teeth per children4. Parents have main role
quiet apprehensive. The high prevalence of dental in providing the information and encouraging a healthy
and living. The knowledge, beliefs, and attitudes of
parents
affect oral health, eating habits and the health behaviors
Corresponding Author: Phone: +62 31 503 0255
Taufan Bramantoro Email: [email protected]
Department of Dental Public Health,
Faculty of Dental Medicine, Universitas Airlangga,
Jl. Mayjend Prof Dr Moestopo 47, 60132
Surabaya, Indonesia
of children5. Parental behavior, especially mothers,
affects the oral health of children because
mother acts as a primary caregiver and the ultimate
decision maker6,7socioeconomic status, oral
health behaviors of children and their parents.
Oral health status of children was examined. The
parent and their children oral health relationship
were tested using regression and correlation
analysis. Results. About 222 parents and
868 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 868

children participated in the study. There was a the study had consented to voluntary informed consent.
significant relationship between history of having Respondents in this study were educated working
dental problems in parents and dmft index in their mothers aged 21-40 years.
children (P = 0.01).
Research Design: This cross-sectional study was
The Central Bureau of Statistics in Banjarbaru, conducted on 101 working mothers in Banjarbaru.
South Kalimantan, stated that in 2015, 62.45% of Sampling was done by cluster random sampling.
Sample criteria were mothers who worked and had
women worked as a bureaucrat. Women working in
preschool children aged 5-6 years. Data was obtained
the public sphere for economic and social motivation; using questionnaires. Instrument behavior consisted of 6
to increase family income and not depend on husband 8, statements that contained the behavior of mothers in the
while the social motivation are education level, free dental health of preschool children aged 5-6 years. Each
time, seeking for experience and self-actualization 9. answer was given with a score of 0-1.
The socio-economic status of the family greatly affects
Statistical Analysis: Data were analyzed using SPSS 16
the family’s need compliance to achieve a prosperous
for Windows. Nonparametric Descriptive Statistics used
standard of living and maximum health10.
logistic regression with the level of significance value
Working women in Banjarbaru are classified to was <0.05.
middle-class society for having a fixed income and well Results
educated. Middle-class society is a social class with
occupation and fixed income, modern society which There were two independent variables, age and
is economically prosperous, and well-educated and education, and one dependent variable, the behavior of
the dental health of the mother. All variables can be seen
considered as an important person by the surrounding
in Table 1. There were 33 (32.7%) working mothers
society11. Health behavior is formed by three main aged
factors; predisposing factors, namely knowledge, 21-30, 68 persons with age 31-40, 22 persons (21.8%)
attitude, belief, values, age, education, occupation, and with low education, and 79 persons (78.2%) with high
family economic status. The second are supporting education. Analysis using SPSS version 16 Software
factors are the physical environment, health facilities for Windows showed that there was no significant
and infrastructure and health program. The last is relationship between educated working mothers’ age on
supporting factor of the attitudes and actions of health dental health behaviors of a preschooler. The results can
workers or others who become role models12. be seen in Table 2.

The purpose of this study was to analyze the Table 1: Distribution of age and education of
relationship between age and education of working working mothers in Banjarbaru
mothers on the dental health behavior of preschool
children aged 5-6 years in Banjarbaru, South
Kalimantan. Variables Category Total Percentage
Age of 21-30 years 33 32.7
Method caregiver 31-40 years 68 67.3
Education of Low 22 21.8
The study was approved by the Medicine Health caregiver High 79 78.2
Research Ethical Clearance Commission (016/HRECC.
FODM/III/2018). Each respondent who participated in Total 101 100
Table 2: Cross-tabulation of the relationship between age and education of working mothers on dental
health behavior in preschool children aged 5-6 years in Banjarbaru

Age Education
Mother behavior 21-30 31-40 Low High
OR Sig. OR Sig.
% % % %
Telling children to clean their teeth Bad 78.8 77.9 81.8 77.2
0.963 0.945 1.348 0.647
after meal Good 21.2 22.1 18.2 22.8
Having their children clean their Bad 60.6 51.5 63.6 51.9
1.297 0.574 1.647 0.468
teeth before going to bed at night Good 39.4 48.5 36.4 48.1
Conted…

Cleaning teeth every morning after Bad 48.5 39.7 50 40.5

1.313 0.550 1.320 0.591
breakfast and night before bed Good 51.5 60.3 50 59.5
Allowing children to eat snacks Bad 36.4 42.4 36.4 41.8
0.802 0.635 0.869 0.791
every day Good 63.6 57.4 63.6 58.2
Telling children to use toothbrushes Bad 9.1 17.6 0 19
0.75 0.684 0.000 0.998
and toothpaste every day Good 90.9 82.4 100 81
Having their children rinse after Bad 78.8 60.3 68.2 65.8
2.678 0.063 0.758 0.625
eating Good 21.2 39.7 31.8 34.3
Mother’s behavior in telling children to clean teeth and education (p = 0.999, OR = 0.000). At the age of
after every meal had no significant relationship with age 21-
(p = 0.945, OR = 0.963) and education (p = 0.647, OR =
1,348). At the age of 21-30 years old, mother’s behavior
on dental health was mostly bad as much as 78.8% with
low level of education equal to 81.8%, whereas at
age
31-40 years old, mother’s behavior on dental health was
mostly bad as much as 77.9% with high education level
of 77.2%. Mother’s behavior in telling children to clean
teeth before bedtime had no significant relationship with
age (p = 0.574, OR = 1.294) and education (= 0.468, OR
= 1.467). At the age of 21-30 years old mother’s
behavior toward dental health was mostly bad as
much 60.6% with low education level equal to 63.6%,
whereas at age
31-40 years old, mother’s behavior to the dental health
of child was mostly bad as much 51.5% with the higher
education level of 51.9%. The behavior of mothers to
clean the teeth every morning after breakfast and the
night before bed had no significant relationship with age
(p = 0.55, OR = 1.313) and education (p = 0.591, OR =
1.32). At the age of 21-30 years old, mother’s behavior
toward dental health of children was mostly good
as much as 51.5% with low education level of 50%,
whereas, at age 31-40 year, majority of mother behavior
to dental health of child was mostly good as much
as
60.3% with education level high of 59.5%. The behavior
of mothers who let children eat a snack every day had no
significant relationship with age (p = 0.635, OR = 0.802)
and education (p = 0.869, OR = 0.998). At the age
of
21-30 years old, mother’s behavior toward dental health
of children was mostly good as much as 63.6% with low
education level equal to 63.6%, whereas at age 31-40
years old, mother’s behavior to dental health of child
was mostly good as much as 57.4% with high education
level of 58.2%. Mother’s behavior in telling children
to use toothbrush and toothpaste every day had no
significant relationship with age (p = 0.684, OR = 0.75)
30 years old, mother’s behavior toward dental health of
children was mostly good as much as 90.9%, although
they had low education, Whereas, at age 31-40 years old,
mother’s behavior to dental health of children was
mostly good as much as 81% with high education level
equal to
58.2%. The mother’s behavior of having a
mouthwash
after eating had no significant relationship with age
(p
= 0.063, OR = 2.676) and Education (p = 0.625,
OR =
0.758). At the age of 21-30 years old, mother’s behavior
toward dental health was mostly bad as much as 78.8%
with a low level of education equal to 68.2%. Whereas,
at age 31-40 years old, mother’s behavior to the dental
health of children was mostly good as much as 60.3%
with the high education level of 65.8%.

Discussion

According to the literature, behavior building is

affected by attitude and knowledge, which can be gained
from both formal and non-formal education13. Previous
studies stated that education level reflect knowledge and
skills to make health behavior choices14,15. The mothers’
dental health behavior is an important factor in building
the children’s dental health behavior6,14socioeconomic
status, oral health behaviors of children and their parents.
Oral health status of children was examined. The parent
and their children oral health relationship were tested
using regression and correlation analysis. Results. About
222 parents and children participated in the study. There
was a significant relationship between history of having
dental problems in parents and dmft index in their
children (P = 0.01). Education may have various impact
on individual, depend on personality, social environment,
culture, and perception. Besides, education also increase
the career opportunity. The working environment in
public sector has high pressure that may induce stress,
and affecting a person behavior, hence, behavior is more
influenced by personality of a person than the level
of
education16,17. The result is in accordance with previous of their work16,17. Exhaustion after work tends to make
research which showed that the level of education does mothers do not care about the dental and oral health
not affect the working mother’s behavior toward the of children. This is in accordance with the results of a
dental health of preschool children aged 5-6 years. study that states that good knowledge was not always
Education is a program to develop personality and directly proportional to the pattern of parenting6,24–
abilities that last a lifetime. The higher education, the 26
socioeconomic status, oral health behaviors of children
easier the person to receive information. The more and their parents. Oral health status of children was
information that comes in, the more the knowledge examined. The parent and their children oral health
gained. Knowledge is very close to education, so it is relationship were tested using regression and correlation
expected that someone with higher education will have analysis. Results. About 222 parents and children
better knowledge, including health care12,18. participated in the study. “There was a significant
relationship between history of having dental problems
Table 2 showed that the mother’s behavior toward
in parents and dmft index in their children (P = 0.01”,
child’s dental hygiene is not correlated to education.
meaning that although the mother has a good knowledge
Lack of knowledge and access to information, causing
about oral health, it does not necessarily make her have
a person to have limited knowledge about the hazard of
a good attitude to apply the knowledge.
unhealthy behavior so less motivation to adopt healthy
behavior16. Learning process may enhance professional
skills and specific knowledge that are still relevant to Conclusion
general knowledge19. Education plays an important role Age and education of working mothers do not affect
in caries prevention. Parents with higher education had dental health behaviors in preschool children aged 5-6
more concern to the oral health of children, that make years in healthcare prevention and maintenance efforts.
them have a better oral health behavior 20,21. Behavior is However, the personality of the caregiver affects this
the biggest factor affecting one’s health. Developmental behavior. Caregivers who work tend to have a high
psychology states that the age of 18-40 years is an level of stress so that after coming home from work, the
early adulthood. As getting older, the maturity and behavior that appears is the behavior as it is, meaning
strength of a person will be more mature in thinking and not so concerned about the dental health of children.
work22. Danang and Irdawati stated that age is one of
the factors that influence mothers to be able to run the Conflict of Interests: None declared
role of optimal care. The age of the mother or the parent
Source of Funding: This research is self-funded.
who has reached maturity in thinking and being able to
properly educate and nurture the child will be able to
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DOI Number: 10.5958/0976-5506.2019.01687.5

Relationship between Behavior and the Use of Personal

Protective Equipment to Pesticide Consumer Farmers in
Tonrong Rijang Village Baranti District Sidenreng Rappang
District

Zaenab1, Ashari R1, Nurmin1

1
Health Polytechnic of Ministry of Health in Makassar, Indonesia

ABSTRACT
Agriculture is one of the most important areas. However agricultural life is closely related to the use of
pesticides that can cause health problems. To minimize health problems is one effort that can be done with
the use of a complete Protective Tools. The type of research used is an analytical survey with Cross
Sectional approach with the population of rice farmers in Tonrong Rijang Village Baranti Subdistrict
Sidenreng Rappang Regency as many as 334 HH with sample 67 HH. Determination of the number of
samples in this study was determined by using Cluster method and data retrieval was done using Random
Sampling Method. Data processing is done by using Chi Square test with SPSS 25, Microsoft excel, and
Microsoft word. The results of this study explain that farmers with high knowledge level of 44 people
(66%), who have high Protective toolsusage as many as 21 people (31%) and who have the use of PPE
while as many as 23 people (34%). Farmers with a moderate level of knowledge of 23 people (34%), who
had high Protective toolsusage of 7 people (11%) and those with PPE were 16 (24%). Farmers who have a
high attitude (good) as many as 55 people (82%) who use high Protective toolsas many as 21 people (31%),
while those using PPE were as many as 34 people (51%). Farmers who have moderate attitude (less good)
as many as 12 people (18%) who use high Protective toolsas many as 7 people (10%) and who use PPE
while as many as 5 people (8%). Based on result of chi square test that obtained is p value 0,173 (p value>
0,05) on knowledge and p value 0,2 (p value> 0,05) at attitude. So it can be concluded that there is no
relationship between behavior with the use of personal protective equipment on pesticide user farmers in
Tonrong Rijang Village Baranti Sub-District Sidenreng Rappang.

Keywords: Farmer, Personal Protective Equipment, Knowledge,

Attitude
Introduction agricultural sector, one of the ways they are the pesticide
use to decrease the disruptor factors of production such
Agriculture is one of the most important fields in
as pests. [6].
fulfillment of a need for a society where Indonesia is
an agricultural country that is predominately live in Massive use of pesticides can cause health problem
agriculture. The number of farmers reached 40% of mainly on farmers sprayers. One of the impacts caused
the total workforce in Indonesia or about 46.7 million. due to the use of pesticides are poisoning on rice
With the growing population every year, people start farmers. One of the efforts to prevent pesticide
to think to improve the results of its production in poisoning on farmers is by the use of complete
the Protective self tools, such as masks, work clothes, boots,
and gloves. [8]

The World Health Organization (WHO) said that

Corresponding Author: the negative impact of pesticides for public health is
Zaenab highly toxic and dangerous. Direct contact with this
Health Polytechnic of Ministry of Health, acute toxicity risk pesticides or chronic. Headache,
Makassar, Indonesia nausea, vomiting and so forth even irritation on the skin
Wijaya Kusuma Raya Street 56 Makassar, Indonesia and blindness are symptoms of acute poisoning from
Email: [email protected] pesticides. Data from the World Health Organization
873 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 873

(WHO), 1-5 million cases of pesticide poisoning occur retrieval is performed using a Random Sampling
in workers in the agricultural sector where the majority Method based on the Joseph Muri Suharsimi
of cases occur in developing countries that 20,000 Arikunto method[1] [4]. Sample were taken
inhabitants got fatal effect due to the use of pesticides[3]. from 20% of the total population. Because the
population is more than 100 people in the village
Materials and Method of Tonrong Flint with calculation as follows:
1. The location of the research: The location of the z Dusun Mattonrong Salo : 191 KK
research conducted in the village of Tonrong Sub-
z Dusun Tonrong Rijang : 143 KK
district Baranti Flint District Sidenreng Rappang.
The area of Tonrong village of Flint around 340 z 191 KK x 20 % : 38 KK
ha/m² with 1,318 inhabitants with 338 families. z 143 KK x 20 % : 29 KK +
2. Population and Sample: The population in 67 KK
this research is the entire rice farmers in the 3. Data Analysis: Data analysis was done using the
village of Tonrong Sub-district Baranti Flint table along with the discussion and concluded by
District Sidenreng Rappang which is 334 Family. using the Chi Square test using SPSS with 25,
Determined using the method of Cluster and Data Microsoft excel, and Microsoft word.

Finding
1. The relationship between knowledge of the farmers with the use of protective self

Table 1: Distribution of Respondents based on knowledge of the Protective tools

Knowledge Amount Percentage(%)
High 44 66
Moderate 23 34
Low 0 0
Total 67 100
Source: Primary Data 2018
Table 2: The relationship between knowledge of the farmers with the use of the Protective Tools
Penggunaan Protective Tools
Amount P Value
Low Moderate Higt
High 0 23 21 44
Knowlege Moderate 0 16 7 23
0.173
Low 0 0 0 0
Total 0 39 28 67
Source: Primary Data 2018
2. The relationship between the attitudes of Farmers with the use of protective self

Table 3: Distribution of Respondents based on their attitude to Protective Tools

Attitude Amount Percentage (%)
High 55 82
Moderate 12 18
Low 0 0
Total 67 100
Source: Primery Data 2018
Tabel 4: Relation between attitude with the us of Protective tools
Protective toolsuses
Amount P Value
Low Moderate High
High 0 34 21 55
Attitude Moderate 0 5 7 12
0.2
Low 0 0 0 0
Amount 0 39 28 67
Source: Primary Data 2018

Table 5: Respondent distribution base on the use of less knowledge and do not wear full personal
protective tools protection as much as 32 people or 94.1%, while
respondents who have a knowledge of good
Protective toolsuses Amount Percentage (%) and
simply not wearing full personal protection a
High 28 42 number of 13 people or 28.3%. Respondents with
Moderate 39 58 less knowledge and wear full personal protection
Low 0 0 is 2 persons or 5.9% while the respondents had the
Total 67 100 good knowledge and enough wearing Protective
Source: Primary Data 2018 toolspeople or 71.7%.
The results of this research in line with the
Discussion Shobib research[7] about the relationship between
knowledge and attitudes with the practice of using
Protective toolsthemselves at the peasant pesticide
1. The relationship between knowledge of the users in the village Curut Penawangan Kec
farmers with the use of protective tools: years
Based
on the results of the study indicate that there is 2013 from Grobogan Regency the results of
no
significant relationship between knowledge with statistical tests knowledge with practice obtained
the use of protective toolson farmers in the p value 0,658 (p > 0.05) showed no meaningful
village
of Tonrong Sub-district Baranti District relationship between knowledge with practice of
Sidenreng
Rappang. It is based on the results of a test of using Protective toolson farmers users of
chi
square p is the value obtained 0.173 (p value 0.05 >). pesticides. Behavior or practices of farmers in the
The results of this research shows that most farmers use of the Protective toolsinfluenced many factors,
had a high level of knowledge 44 people (66%) and although the good farmer’s knowledge of the use
moderate level of knowledge are 23 people (34%). of Personal Protection when interacting with
Where a Farmer has a high level of knowledge pesticides, but in practice it may not be
as
much as 44 people (66%), which have a high appropriate, the availability of the protective tools,
use
of Protective toolsas many as 21 people (31%) and comfort, season and weather that did not allow,
who have moderate use of the Protective and it because follows the behavior of people or
toolsare
23 people (34%). Farmers who have a moderate fellow farmers, so knowledge is not necessarily
level of knowledge as much as 23 people influential or relate to a person’s behavior or
(34%),
which have a high use of Protective toolsas practices.
much
as 7 persons (11%) and who have the use of the In this study the majority of farmer > 50 year old
Protective toolsare as much as 16 people (24%). with working period of >10 years and most of the
The results of this study are inconsistent with farmers did not finish Elementary School and some of
research Faris Khamdani about the relationship
[5] them have to high school education level. Farmers who
between Knowledge and attitudes with the use did not finish elementary school most have moderate
of the tool of self protector Spray Pesticides knowledge levels, while farmers who had education up
on
farmers in the village of Angkatan Kidul 2009 to secondary school have a high knowledge.
obtained a result that respondents who have Farmers who
have moderate knowledge are (farmers who protective toolsas much as 16 people (10%) and
did not finish elementary school) most of them the use of the protective toolsas many as 5 people
do not use the complete self protective tool, (8%). Although most farmers have high attitude
whereas farmers who have the knowledge are towards the use of protective tools, they still don’t
farmers who have high education up to Secondary use protective toolsthemselves in action. There is
School Upper Intermediate mostly use Protective still lacking of using protective tools. So it can be
toolsthemselves. This shows that formal education seen that attitude does not necessarily reflect
provides a major influence in the open insight one’s actions or the actions of someone often at
and understanding of the new values that exist in odds with his attitude.
the environment. Someone with a high level of
The results of this research are consistent with
education will be easier to understand the changes
2013 Shobib research [7] about the relationship
that occur in their environment and the person
between knowledge and attitudes with the practice
will absorb those changes if the feel is beneficial
of wearing Protective toolsin the village of Curut
for him. Someone who never attended formal
Penawangan Kec years 2013 from Grobogan
education estimated will more easily accept and
Regency the results of statistical tests attitude with
understand about health messages through this
practice obtained p value 0,902 (p > 0.05) showed
extension as well as the mass media [5].
no meaningful relationship between attitude with
Farmers ‘ knowledge need to be improved in the practice of wearing protective toolsto farmer
order to pay more attention to the use of that is pesticide users.
protective self, especially about the negative
The results of this research are also in line with
effects or dangers that can be caused from
the research of Usman Rifai [6] about factors
pesticides if they do not use Protective
associated with compliance with the use of
toolsthemselves, provide guidance and simulation
Protective toolsthemselves at the rice farmer in
about the use of Protective toolsthemselves with
Dukuh Sodong Village Semarangtahun Town
good and true, such as hats, masks, gloves, long
Mijen Subdistrict Purwosari 2017. From the
sleeve shirt, long pants and boots and danger from
statistics, there is no relationship between the
not using protective tools and the need for
protective about the posters themselves at the attitude of compliance with the use of Protective
peasant must be used in order to remind farmers toolsbecause in Dukuh Sodong.They assume that
and farmers ‘ awareness of the importance of the wearing of protective tools can be interfere
safety and health in the work. with work as well as the uncomfortable feeling
while using protective tools.
2. The relationship between Attitude with the use
of Protective toolsfrom Pesticide Users in the Attitude is a tendency to hold actions against an
village Tonrong Rijang: Based on the results object, with a way of stating the existence of signs
of the study indicate that there is no significant for enjoying or not enjoying the object. Attitude is
relationship between the attitude to the use of just part of human behavior. Attitude is a reaction
protective tools to pesticide users on farmers or response is still closed from someone’s
in the village of Tonrong Rijang Sub-district response to a stimulus or object. The attitude
Baranti District Sidenreng Rappang. It is based on shows in the real connotation of congruency
the results of a test of chi square p is the value reaction to certain stimuli in everyday life is the
obtained by 0.2 (p value 0.05 >). The results of emotional nature of the reaction against the social
this research shows that most of the farmers have stimulus[5].
a high attitude that as many as 55 people (82%) This research show that the attitude of farmers
and moderate were 12 people (18%). Where a in using protective tools is good, but despite the
Farmer has a high attitude towards the use of the attitude of farmers already well there are several
protective tools. Protective toolshigh user by as factors that affect the use of Protective Tools,
much as 21 people (31%), while the use of such as comfort in work. Most of the farmers are
moderate user as many as 34 people (51%). not using protective gloves namely self as much
Farmers who have an attitude of moderate (less as 59 respondents or 88% because farmers
good) that uses high feel
uncomfortable while working (mix and spray) Ethical Clearance: The ethics of this study were
wear gloves. The hand is one of the important obtained from the Ethics Commission for Health
aspects that need to be protected because farmers Research, Health Polytechnic of Ministry of Health
use the hands to take, mixing and spraying of in
Makassar, Indonesia.
pesticides, the use of gloves may also reduce the
risk of entry of pesticides from the skin, as many REFERENCE
as 54 respondents or 81% do not use boots in the
1. Arikunto, Suharsimi. A Research Procedure
works because it feels uncomfortable, besides the
Approach to Practice [Internet]. PT Rineka
weather factor also affects the rainy season will
Copyright. 1996. [cited 3 January 2018] Available
be very hard work by wearing boots, and as many
from: repository.usu.ac.id.
as 51 respondents or 76% did not wear a mask
because it feels stuffy or difficulty breathing when 2. Cecep T, and Erlisya PM. Environmental Health
spraying pesticides and the unavailability of the and Safety. Yogyakarta: Nuha Medika: 2013.
mask should be used.
3. Frity. Pesticide Exposure Risk Factors On
In this study the majority of farmers have Horticultural Crops In Farmers Plantation Wawo
time Tomohon 2017. Ejournalhealth 2017. [Cited
work > 10 years and some farmers have time 23 November 2017].Available online: https://
work
ejournalhealth.com/index.php/kesmas/article/
≤ 10 years. Farmers work with > 10 years have a view/41.
high attitude (good) on the use of protective tools
so well with farmers who have working 4. Joseph M. Research Methods, Jakarta: PT
period Interpratama Mandiri Dawn; 2017.
≤ 10 years also has a great attitude towards the 5. Khamdani, Faris. The Relationship Between
use of protective tools themselves. However, both Knowledge and Attitudes with the Use of the Tool
farmers with a working period of >10 years or of self Protector Spray Pesticides on Farmers in the
farmers with work that has ≤10 years high attitude Village of Force compelled the Starch of the
in the use of protective tools themselves mostly year
have usages that are self protective tool in terms 2009. Semarang 2009. [cited 23 November 2017]
of are not use protective tools themselves. This Avaiable from: lib.unnes.ac.id/123/6094.pdf
shows that although the farmer who has a long
working period though, that have experience in 6. Rifai, Usman. Factors Associated With
doing his job has not been able to implement the Compliance With the Use of Protective Tools
full use of Protective tools in protecting himself Themselves at the Peasant Rice In Dukuh
when doing spraying. Subdistrict (kecamatan) Sodong Purwosari Mijen
Semarang year 2017. 2017 [cited 23
November
Conclusion
2017] Available from: eprints. dinus.
There is no relationship between the behavior with ac.id/22506.
the use of protective tools themselves on rice farmers 7. Shobib, Muhammad N, et al. The Relationship
in the village of Tonrong rijang Sub-district Baranti Between Knowledge and Attitudes with the
District Sidenreng Rappang, where p value = 0.173 (p Practice of Wearing (Protective Tools) Tool is
value 0.05 >) on knowledge and p value = 0.2 (p value a Self Protective Pesticide Users on Farmers
0.05 >) on attitude. in the Village of Curut Excl. Penawangan Kab
Grobogan Year 2013. 2013 [cited 2017 November
Conflict of Interest: In this study between researchers
23]. Available from: Eprints.dinus.ac.id,
and research subjects did not have a conflict of interest,
because subjects did not have personal or informal 8. Wismaningsih, Endah RD and Ias O. Factors
relationships with researchers. Associated with the Use of Self Protector
(Protective Tools) on Sprayers Farmers in
Source of Funding: The source of funds in this district Ngantru Tulungagung District. 2015
study [cited 23 november
came from self funding in 2018.
2017]. Available from:
https://ojs.iik.ac.id.
DOI Number: 10.5958/0976-5506.2019.01688.7

Hazard Identification, Risk Assessment, and Determining

Controls in Laboratories

Ais Assana Athqiya1, Dani Nasirul Haqi1, Putri Ayuni Alayyannur1, Indriati Paskarini1, Fauziah Mukti
Sugiharto1
1
Department of Occupational Safety and Health, Faculty of Public Health, Universitas Airlangga,
Surabaya, East Java, Indonesia

ABSTRACT
A laboratory is a place to carry out experiments. Working in a laboratory means having zero chance to
perform reckless behaviors in performing or using equipment and materials provided in a laboratory. A
laboratory as a place with high chances of hazard occurrence is required to be examined by implementing
Hazard Identification Risk Assessment Determining Control (HIRADC) analysis, which also an essential
element in occupational safety and health management system due to the fact that it relates to the endeavor
to prevent and control hazards used to determine the objectives and intentions of occupational safety and
health. HIRADC analysis in this research is expected to reduce hazard risks that are likely to be discovered
in laboratories. This research is performed in 2 nutrition laboratories in the Faculty of Public Health,
Universitas Airlangga. The data used are the primary data obtained from observation. The results show that
there are 15 hazard identifications from two identified laboratories. The highest hazard level is medium-
risk, which consists of 3 hazard identifications. Risk controls need to be continuously implemented in
order to control hazards that might be occurred.

Keywords: laboratory, HIRADC,

hazard
Introduction managed system. The number of hazard aptitude is
determined by the possibility of the occurrence of the
A laboratory is a place to carry out an experiment.
incidental accidents as well as by the severity it may
Working in a laboratory requires cautious behavior
cause.2
in treating or using equipment and materials in the
laboratory. This is intended to scale down the possibility According to the International Labour Organization
of occupational accidents in a laboratory. Amongst of (ILO), 2.78 millions of workers are reportedly dead each
the potential hazards that are likely to happen in a year due to occupational accidents and occupational
laboratory are fire, poisoning, and equipment damage.1 illnesses. Approximately 2.4 million (86.3%) of these
deaths are caused by occupational illnesses, while
Everything that contains danger is fundamentally
more than 380,000 (13.7%) are caused by occupational
sustained by the risk management to control hazards that
accidents.3 Referring to the data provided by National
can potentially cause several risks in occupational safety
Social Security (re BPJS Ketenagakerjaan), the number
and health to prevent unwanted occupational accidents
of occupational accidents in Indonesia is still massive.
comprehensively, planned, and structured under a well-
In 2015 alone, 110,285 cases of occupational accidents
were disclosed, while in 2016, 105,182 cases were
detected. In addition, until August 2017, National
Corresponding Author: Social Security attained the number of 80,392 cases of
occupational accidents.4
Dani Nasirul Haqi
Department of Occupational Safety and Health, The big number of accidents must not be
Faculty of Public Health, Universitas Airlangga, underestimated. A laboratory as a workplace in which
Surabaya, East Java, Indonesia several of hazard risks can be discovered must have
Phone: +62857 3039 6977 control to reduce the number of occupational accidents
Email: [email protected] in Indonesia. OHSAS 18001 is one of occupational
safety and health management systems with an
international
878 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 878

standard that aims to provide safety for workers from Nutrient Processing Analysis. These locations were
unwanted matters that might arise from workplaces chosen as the locations of the research due to the fact
or working activities itself. In accordance with the that there had not been similar research carried out.
requirements given by OHSAS 18001 clause 4.3.1, an The variables used in this research were the working
organization must set a procedure and conduct Hazards activities in the laboratories, hazard sources, assessment,
Identification, Risk Assessment, and Determining and risk control. The data gathered from this research
Control, which also known as HIRADC.5 are known as the primary data, which were obtained by
observation. In addition, the results of the observation
A laboratory as a place with high risk of danger
were presented in the form of narration and table before
should also be carried out by HIRADC (Hazard
analyzed descriptively to draw a conclusion.
Identification Risk Assessment Determining Control)
analysis that roles as an indispensable element in Risk Assessment: There are three main focuses in
occupational safety and health management system HIDARC, namely the attempt to perform hazard
since it directly relates to the prevention and hazard identifications and its characteristics, which is followed
control used to determine the objectives and intentions by filling up the assessment, risks of existing hazards,
of occupational safety and health. The carried out and last, recommending control endeavors that are likely
HIRADC analysis is expected to reduce hazard risks that to be executed.
might arise in a laboratory.
Hazard identification is done to monitor high-risk
workloads and underline the hazards related to certain
Method
equipment. Hazards in a working environment can be
Study Population and Analysis: This research categorized into three major groups, for instance, health
implemented observational approach and cross- hazards, safety hazards, and environment hazards. After
6

sectional. The data were analyzed descriptively by that, evaluate risks whether the risks are acceptable or
elaborating the hazard potentials in the area in which the not is measured. To measure the score level of the risk,
research was conducted to obtain risk assessments and it is important to understand two main components,
determining controls. This research was carried out in namely Likelihood, and Severity.The criteria to assess
Nutrition Laboratories of Faculty of Public Health, Likelihood can be seen in Figure 1, while the criteria to
Universitas Airlangga Surabaya, namely the Laboratory assess Severity are presented in Figure 2.
of Nutrition Processing and the Laboratory of
Biochemistry and

Source: Department of Occupational Safety and Health Malaysia (2011)

Figure 1: Likelihood Criteria

Source: Department of Occupational Safety and Health Malaysia (2011)

Figure 2: Severity Criteria
After obtaining the severity level of risks, the control to suppress the risk level to become as low as possible is
likely to be done.7

Result

According to the observation, in the Laboratory of Biochemistry and Nutrient Processing Analysis, five items of
hazard identifications as displayed in Table 1 were discovered.

Table 1: Hazard Identifications in the Laboratory of Biochemistry and Nutrient Processing Analysis
No. Activity Hazard Source
1. Food nutrient analysis (mixing Acid reagent and concentrated base (heated up to 400° C in a fume hood)
food ingredients with reagents) Heat from the fume hood
2. Biochemistry analysis (mixing Reagents (Acid and strong base with high concentration)
reagents and human body sample) Droplets from human (blood, urine, saliva, hair)
3. Biochemistry and nutrient analysis
No First Aid kit in the laboratory
practices with a minor accident

Table 2: Hazard Identifications in the Laboratory of Nutrition Processing

No. Activity Hazard Source
Sharp food ingredients
1. Peeling and cutting food ingredients to be processed Knife
Bacteria
2. Washing food ingredients and utensils Bacteria
LPG
3. Cooking foods on a stove and deep fryer Heat
Hot oil
Heat
4. Cooking foods using a microwave
Electricity
5. Cooking foods using an oven Heat
6. Food processing practices with a minor accident No First Aid kit in the laboratory

The hazard sources discovered in both laboratories contribute to risk accidents and diseases caused by the work
done in both locations. Referring to the terms proposed by AS/NZS 4360, in order to correctly measure the risk
level of each hazard, the assessment of two components, Likelihood and Severity, from point 1 to 5 based on the
possible risk occurrences needs to be done.7 The information is presented in Table 3 and Table 4.

Table 3: Likelihood and Severity of the Laboratory of Biochemistry and Nutrient Processing Analysis
Hazard Source Risk Likelihood Severity Risk Level
Acid and concentrated base reagent Fluid exposed to the skin 1 3 Low
(heated up to 400° C in a fume hood) Fumes inhaled and enter the
2 3 Moderate
respiratory tract
The heat from the heating devices
Heat from a fume hood 1 2 Low
exposed to the hands
Fluid exposed to the skin 1 3 Low
Reagents (Acid and strong base
with high concentration) Fumes inhaled and enter the
1 3 Low
respiratory tract
Conted…
Droplets exposed to the skin tissues 1 1 Low
Droplets from human (blood, urine,
saliva, hair) Droplets swallowed or inhaled and
1 2 Low
enter the human body
Injuries cannot be treated with First
No First Aid kit in the laboratory 2 3 Moderate
Aid and caused more severe wounds

Table 4: Likelihood and Severity of the Laboratory of Nutrition Processing

Hazard Source Risk Likelihood Severity Risk Level
Sharp food ingredients Sliced by sharp food ingredients 1 2 Low
Knife Hands sliced by a knife 2 2 Low
Bacteria Food contaminated by bacteria 1 1 Low
Food ingredients and utensils contaminated by
Bacteria 1 1 Low
bacteria
LPG Exploding and fire 1 4 Low
The heat from the stove or heat-conductor utensils
Stove heat 2 2 Low
exposed to the hands
Hot oil Hot oil exposed to the hands 2 2 Low
Food heat Hot food products (burn) exposed to the hands 2 2 Low
The electric shock when connecting the cable to
Electricity 1 2 Low
the socket
Hot oven and food products (burn) exposed to the
Oven heat 2 2 Low
hands
No First Aid kit in the Injuries cannot be treated with First Aid and
2 3 Moderate
laboratory caused more severe wounds

The following step to be performed is assessing risk levels by alluding the risk matrix as shown in Figure 3. The
meeting point of Likelihood and Severity is the one that determines whether the risk level belongs to a low,
moderate, or high level. Moreover, in elaboration, if the meeting point of Likelihood and Severity is in the green
area, it can be presumed that the risk level is low. However, if the meeting point is in the yellow area, it is
considered as moderate and high if it belongs to the red area.7

Source: Department of Occupational Safety and Health Malaysia (2011)

Figure 3: Risk Matrix
The high-risk level requires immediate actions 2. The Laboratory of Nutrition Processing: In the
to control hazards in accordance with five hierarchy Laboratory of Nutrition Processing, activities to
controls. The moderate-risk level, on the other hand, process foods are the main activities performed.
compels designed approach in hazard controls as well The processing equipment that is most likely to
as executes alternative plans if needed. Additionally, cause danger is a knife, providing it has a sharp
for the low-risk level, the hazards are still likely to be side that can be a cause of grazes. Additionally,
accepted and not in need of further control. 7 stoves and ovens in high temperatures that can
cause burns and LPG that may explode. Other
Discussion than that, food ingredients such as pineapples,
shrimps, and fish can also be considered as the
Hazard Identification potential hazard sources. If food ingredients are
contaminated with bacteria due to unclean
1. The Laboratory of Biochemistry and Nutrient
washing process or un- fresh ingredients, the
Processing Analysis: In the hazard identification
bacteria itself may transfer to the laboratory
discovered in the Laboratory of Biochemistry and workers. Moreover, heated oil is presumably
Nutrient Processing Analysis, it was settled that causing accidents, for example, hands splashed by
the reagent is the main hazard in the laboratory. hot-temperature oil. The Laboratory of Nutrition
Other than that, the reagent liquid is believed to be Processing, unfortunately, does not provide First
dangerous if exposed to the human body. Moreover, Aid kit, resulting in minor accidents cannot be
the reagent needs to be heated. Thus, it can be immediately treated.
presumed that beside the reagent liquid that
originally contains chemical matters, instruments Risk Assessment
and utensils with high temperatures as well as 1. The Laboratory of Biochemistry and Nutrient
fumes from the reagent heating process are also Processing Analysis: The average hazard level
undoubtedly alarming. Unfortunately, the subjects discovered in the Laboratory of Biochemistry and
who perform such tests seem to underestimate the Nutrient Processing Analysis is the low-risk level,
consequences and resulting to inhale the alarming providing the occurrences hardly arise when
fume. doing such activities in the laboratory. Even so,
the score of 2 in Likelihood aspect is given for
Other than food substances, the Laboratory of
fumes inhaled when processing food ingredients
Biochemistry and Nutrient Processing Analysis
and untreated minor accidents due to the absence
also evaluates the biochemistry taken from
of First Aid kit in the laboratory.
the human body as the sample, for instance,
blood, urine, saliva, and hair. Those samples are As for the Severity aspect, the average point
considered as hazards since they can transmit given for the Laboratory of Biochemistry and
diseases. Therefore, it can be stated that doing Nutrient Processing Analysis is 3. Likewise, the
activities in a laboratory means living close risk of droplets exposed to skin tissues causing
to danger, according to the survey conducted blisters, bruises, wounds, and worries resulting
those hazards be given the Severity point of 1. As
by Education Bureau in 2011/2012 regarding
for the risk of hands exposed to the heat from a
accidents in school laboratories in 401 middle
fume hood and droplets swallowed, the hazards
schools which enlisted the reported 348 cases of
be scored 2 points of Severity aspect since it may
laboratory accidents. From the survey, the results
cause non-permanent disabilities.
showed that 328 people were injured, with the
percentages of 39.1% of grazes, 37.6% of minor From the elucidation above, it can be concluded
burns, 8% of accidents on the eyes, and 7.2% of that there are only two hazards that are considered
exposure to chemical substances. First Aid kit
8 as moderate, namely fume reagents inhaled during
needs to be stacked to anticipate minor accidents. food nutrient analysis and the absence of a First
However, regrettably, there is no First Aid kit Aid kit.
spotted in the Laboratory of Biochemistry and 2. The Laboratory of Nutrition Processing: The
Nutrient Processing Analysis. danger of processing equipment in the Laboratory
of Nutrition Processing such as knives, stoves, and h. Procuring Personal Protective Equipment, such as
ovens be given the score of 2 in Likelihood aspect. heat resistant gloves to minimize the possibility of
The same score is also given to hot oil, food heat, hand exposed to hot equipment
and the absence of First Aid kit. The explosion
of LPG and electric shock accident records are Some of the elaborated suggestions above are
nowhere to be found, causing both hazards to be reckoned to be considered in order to control hazards
given the score of 1 in Likelihood aspect. in laboratories to prevent occupational accidents and
severe occupational illnesses.
For the Severity aspect, the highest score of
Severity, 4, is attained from the explosion of
LPG since it may be resulting in fatal injuries and Conclusion
the damage of properties. In contrast, the lowest
Severity score is obtained by the bacteria in food The Laboratory of Biochemistry and Nutrient
ingredients and processing equipment, which Processing Analysis and the Laboratory of Nutrition
each gets a score of 1. The Severity level with the Processing in the Faculty of Public Health, Universitas
score of 3 is only spotted in the risk caused by the Airlangga come with different types of hazards. The
absence of First Aid kit. As for the other hazards, Laboratory of Nutrition Processing has more potential
the score given is 2 due to the fact that it does not hazards (10 hazards) than the ones in the Laboratory
cause any severe injury. of Biochemistry and Nutrient Analysis (5 hazards).
In broad, it can be stated that all hazard risks in the Nonetheless, the risk levels discovered in the Laboratory
Laboratory of Nutrition Processing on average, of Biochemistry and Nutrient Analysis in moderate-level
attained the score of the low-risk level. Hence, one are reported more with the number of two, obtained
point that cannot be ignored is the absence of First from the risk of inhaling reagent fumes while analyzing
Aid kit, which belongs to the moderate risk level. food substances and the absence of First Aid kit in
the laboratory. On the other hand, the Laboratory of
Risk Control
Nutrition Processing only has one category of moderate-
Control actions are needed to prevent occupational risk level: the absence of First Aid kits. Thus, it can be
accidents that can result to fatal injuries.9 Amongs of the assumed that both Nutrition Laboratories in the Faculty
actions that can be executed are: of Public Health are considered quite safe inasmuch as
a. Administering briefing concerning on the proper no high-risk level of hazards discovered. As a matter
and safe experiment instructions before each of fact, only a few are scored a moderate-risk level.
experiment (Standard Operating Procedure of the However, risk controls are still essential to be done in
experiment and Experimental Instructions) order for the hazards to be controlled.
b. Administering briefing on how to properly and Ethical Clearace: Taken
safely process food ingredients
Source of Funding: Sponsored by University
c. Administering briefing on how to properly use
knives or hazard-possible instruments that it can Conflict of Interest: None
be safely used by the users
d. Administering briefing on proper personnel and REFERENCES
equipment hygiene sanitation
1. Suyitno A., Sukirman. Biology for Junior High
e. Making regulations to wear Personal Protective School. Bogor: Yudhistira. 2008.
Equipment (APD) such as rubber gloves, masks,
goggles, and a laboratory coat 2. Ramli, Soehatman. Occupational Health & Safety
Management System OHSAS 18001. Jakarta: PT.
f. Placing LPG that are far from flammable
Dian Rakyat. 2010.
substances and in a stable temperature
g. Procuring First Aid kits as needed to treat minor 3. Organisasi Perburuhan Internasional (ILO).
injuries caused by minor accidents when doing Improving the Safety and Health of Young
activities in the laboratory Workers. Jakarta: ILO. 2018
4. Anonim, BPJS Ketenagakerjaan. [Internet]. 8. Education Bureau. Results of The Survey on
BPJS. 2018. [cited 22 January 2019]. Available Laboratory Accidents in Secondary Schools
from: https://www.bpjsketenagakerjaan.go.id/ in 2011/2012 School Year. [Internet]. The
berita/18057/Menaker-Hanif-dorong-pemda- Government of the Hong Kong Special
bikin-komitmen-Keselamatan-dan-Kesehatan- Administrative Region. 2013. [cited 29
Kerja-(K3)-di-Wilayahnya. January
5. OHSAS 18001. Occupational Health and Safety 2015] Available from:
Management System Requirements 18001. 2007. http://applications.edb.gov.
hk/circular/upload/EDBCM/EDBCM13055E.
6. Mallapiang, F. dan Ismi A. S. Hazard Potential pdf.
Analysis and Its Control With the HIRAC
Method. Al-Sihah. 2014;6(2). 9. Prihatiningsih, S. dan Tjipto Suwandi.
Application of the HIRADC Method as an
7. Department of Occupational Safety and Accident Prevention Effort on Rewinder Machine
Health Malaysia, 2011. Guidelines for hazard Workers. The Indonesian Journal of Occupational
identification, risk assessment and risk control Safety, Health and Environment. 2014;1(1):73-
(HIRARC). Putrajaya: Ministry of Human 84v
Resources Malaysia, pp. 7-18.
DOI Number: 10.5958/0976-5506.2019.01689.9

Risk Analysis of Accidents and Occupatioal Disease in Ohs

(Occupational Health and Safety) Laboratory

Muhammad Yusuf1, Dani Nasirul Haqi1, Putri Ayuni Alayyannur1, Endang Dwiyanti1, Nur Laili R1
1
Department of Occupational Health and Safety, Faculty of Public Health, Universitas
Airlangga, Surabaya, East Java, Indonesia

ABSTRACT
The application of Occupational Health and Safety is an important aspect that should be applied in a
laboratory unit. Laboratory is a unit used to apply the theories taught in class and also as a means to study
the academic activists. A laboratory is a facility that has potential hazards both directly and indirectly.
Potential hazard is commonly referred to all sources, situations, or activities that could potentially cause
injury (accident) or occupational diseases. Potential hazard causes not only an injury or occupational
diseases caused in working, but can result in losses of material and environment for the surrounding
communities such as fire, explosion or pollution due to the laboratory activities. Hazard in the laboratory is
often not realized by those who are in the laboratory. This is due to the absence of assessment standards and
poor socialization or learning about the potential hazard that make it is necessary to identify the level of
hazard in a university laboratory. The object of this research study was laboratory of Department of
Occupational Health and Safety at Faculty of Public Health, Universitas Airlangga, Surabaya. This research
study was an observational research because the researcher only did observations without giving treatment.
The research design used in this research study was a cross-sectional study because the research study was
conducted at one particular time. The tool used to analyze risk was HIRADC (Hazard Identification Risk
Assessment Determining Control). There were ten hazards that exist in the laboratory. The source of
hazards were seen from the attitude at work, materials, and equipment, environment and the way of
working. The results of the research study found that the risk level in the laboratory of OHS
(Occupational Health and Safety) Department of Occupational Health and Safety Universitas Airlangga
was 60% (low). The control could be done through the engineering control, administrative control, and the
use of personal protective equipment (PPE).

Keywords: Hazard Identification Risk Assessment Risk Control, Hazard, Risk

analysis
Introduction limited scale, by using equipment and material based on
certain scientific methods, in the context of
Workplace certainly has the potential hazard
implementing education, research study, and/or
that can cause accidents. One of the workplaces is
community service (Permenpan RB Number 03 Year
the laboratory. Educational research unit, hereinafter
2010). Laboratory is managed by technicians or
referred to as laboratory, is academic support unit in
laboratory staff known as Educational Laboratory
educational institutions, in the form of closed or open
Institutions.3
spaces, permanent or movable, systematically managed
for testing, calibration and/or production activities on a Educational Laboratory Institutions are positions
that have scope, duties, responsibilities, and authorities
Corresponding Author: to conduct management of educational laboratories
Dani Nasirul Haqi occupied by Civil Servants with rights and obligations
Department of Occupational Health and Safety, given in full by authorized officials. In the laboratory,
Faculty of Public Health, there are rules and orders that must be obeyed by each
Universitas Airlangga, Surabaya, East Java, Indonesia laboratory user.
Phone: +62857 3039 6977
The existing regulations in Indonesia related to the
Email: [email protected]
implementation of Occupational Health and Safety
are
885 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 885

Law Number 1 Year 1970 on Occupational Health and Workplace accidents that occur can not be separated from
Safety. Government Regulation Number 50 Year 2012 the hazards that exist both physical, chemical, biological,
on Implementation of Occupational Health and Safety ergonomic, and other hazards. The occupational accidents
Management System. It states that the Occupational are high electrical tension, scratches, contracting diseases,
Health and Safety Management System applied must be punctured by lancet, and others. Occupational accidents
in accordance with the national policy of Occupational in laboratory unit of Occupational Health and Safety
Health and Safety Management System. OHS must be identified, analyzed, and controlled to prevent the
Management System includes the establishment of OHS workplace accidents.
policies, OHS planning, implementation of Occupational
Therefore, this research study aims to analyze
Health and Safety plan, monitoring of Occupational
the risk of hazards using the Hazard Identification
Health and Safety, evaluation of OHS performance, and
Risk Assessment Risk Control in laboratory unit of
reviewing and improving the performance of OHS.5
Occupational Health and Safety as an effort to prevent
Entrepreneurial or Education Laboratory Institutions and control the risks of occupational accidents and
at least conducts an initial review of Occupational occupational diseases to the laboratory users.
Health and Safety conditions such as hazard
identification, risk assessment, and risk control. Risk Material and Method
assessment and risk control or commonly known as
HIRADC is a method of the OHSAS 18001:2007 This research study was an observational research
standard. Organizations in conducting hazard because the researcher only did observations without
identification and risk assessment must pay attention to giving treatment during the research study. The research
the scope, nature, and time to ensure the method is design used in this research study was a cross-sectional
proactive and provide identification, priority and risk study; the data collection was carried out in a certain
documentation, and application of controls as needed.2 period of time.
The Global Estimates Fatalities reported that 6,000 The data analysis of this research study was
workers worldwide had lost their lives every day due descriptive because the researcher only described
to accidents and work-related illnesses/occupational the process and data collected without analyzing the
diseases. Based on the data from Social Insurance relationships between variables. The tools used in
Administration Organization (BPJS), number of this research study were hazard identification, risk
accidents remained in high each year. In 2015, there assessment, and risk control.
were 110,285 cases of occupational accidents. In 2016,
as there were 105,182 cases of occupational accidents This research study only used primary data obtained
with cases decreased by 4.6%. Meanwhile, currently the through interviews and observations. Interviews were
number of occupational accidents in Indonesia is around carried out to the laboratory staffs who were responsible
80,392 cases.7 for the laboratory unit of OHS or referred to as the
Education Laboratory Institutions. Observations were
Workplace accidents can be caused by mistakes and
negligence in the use of machinery or the equipment in made to obtain information related to work performed,
the workplace, disobeying the work procedures, lack of sources of hazard, existing risks, and risk control
job training, unavailability of occupational health and efforts that had been made. The results of data collected
safety equipment. As well as the workplace accidents and analyzed were presented with narrative text and
that occur in the laboratory. HIRADC tables.

Department of Occupational Health and Safety,

Finding
Faculty of Public Health is a leading educational facility
and is very supportive of the academic community in The laboratory unit of OHS, Department of
developing research study, so that it always striving to Occupational Health and Safety, Universitas Airlangga
increase and improve the best quality of all facilities in it. had various activities; activities that had a source of
Working in laboratory unit of Occupational Health hazard and would pose a risk to Occupational Health
and Safety or working in other laboratory has various and Safety. The HIRADC method was used as a
hazards. first
step that could be used to prevent the occurrence of incorrect position, it could cause muscle pain.
risks that could cause workplace accidents. The first Then, if the bench did not have strong feet, it
step was Hazard identification was performed on ten could also cause accidents.
laboratory activities in the laboratory unit of OHS. The
ten laboratory activities identified the hazard of each At the time of the blood chemistry test using
activity performed. lancet, cotton, and capillary tube, these objects
could transmit other people’s blood from the
The next step was risk assessment of each hazard. remaining blood. In addition, the lancet could
Risk analysis was performed with qualitative methods cause punctured or scratched skin due to the sharp
by assessing aspects of opportunity or likelihood and lancet.
severity which were then evaluated using a risk matrix
At Laboratory unit of OHS, at the time of
as referred to the Australian Standard/New Zealand
delivering the materials, the chair used was not
Standard (AS/NZS 4360: 2004)1.
ergonomic because it did not have a backrest and
Risk assessment was conducted when laboratory a right armrest. In addition, the chair used did not
activities began. The source of hazard had ten risks. have a cushion on the buttocks.
There were six risks with a low category, three risks
Water wash in laboratory unit of OHS could
with a medium category, and one risk with a high
be used. This might cause the chemical that
category. The results of the risk assessment based on the
splashed into the eyes could not be washed easily.
calculation of likelihood and the severity which was
Therefore, these chemicals could cause irritation.
converted using the risk matrix table, will be used as
the next step, that was determining control. Then the equipment in laboratory unit of OHS
was in a mess condition and was not placed in the
Risk control had been performed by the laboratory proper place. So, the equipment could be dropped,
staff on hazards or risks from each laboratory activity damaged, or lost.
based on the findings or events occurred. By trying
2. Risk Assessment: After identification of hazard
to compare the results of the risk assessment with the
was performed, the source of hazard or potential
control efforts, then it will be known what attempts
hazard would have a risk impact. The risk impact
were still less effective. Therefore, hazard control
was categorized into three categories, those
can be performed using a hazard control hierarchy,
were low, medium, and high category. The three
namely elimination, substitution, engineering control,
categories were derived from calculations that
administrative, and the use of PPE (personal protective
refer to AS/NZS 4360:20041.
equipment.
1. Hazard identification: Activities conducted in Risk = Likelihood × Severity
laboratory unit of OHS had a variety of potential Based on the results of the risk assessment, there
hazards such as the use of electrically powered were ten risks. There were six risks with low
equipment, the up and down of the bench, the category, three risks with medium category, and
use of sharp materials, the use of mouthpieces, one risk with high category.
non-functioning of water wash, and equipment
Low-risk categories were the risk of injury and
cluttered or not placed properly. Potential hazard
unable to perform the first aid, disease
of using electrically powered equipment could
transmission through saliva or blood, eye
cause electricity issues that were not in accordance
irritation, time efficiency, and equipment
with the MCB, so that the electricity could be
damage. The risk with the medium category was
interrupted, which might cause short circuit, or
the occurrence of severe injuries, the occurrence
fire.
of symptoms of MSDs (musculoskeletal
Physical fitness practicum activities had potential disorders), and falling equipment could injure
hazards when the bench going up and down. If another person. Then, for a high-risk category,
going up and down a bench happened in an that was electric shock or fire due to a short
circuit.
Table 1: Risk Analysis and Risk Level

Risk
Risk Risk
No. Activity Sources of Hazard Risk Analysis
Total Level
L S
Unable to perform the first
Scratched sharp end of Equipment/sides of
aid in case of accidents and
1. the room sides. the room that could 4 1 4 Low
injuries become more
Cut during practicum. cause injury.
severe.
When doing
Falling down on the practicum, the Causing serious injury.
2. bench at the physical practitioner can be Not yet happened but can 2 3 6 Medium
fitness laboratory. negligent and lead to happen at any time.
accidents.
The use of equipment Electric current is
with electric power not in accordance Electricity off when
3. When the learning with MCB practicum is conducted. It 2 5 10 High
process conducted, it is (Miniature Circuit can cause fire.
often interrupted. Breaker).
When doing
practicum, the
Using someone else’s
practitioner can
mouthpiece that has
neglect to put the Transmission of disease
4. been used in 2 2 4 Low
transducer used, not through saliva.
Pulmonary Physiology
directly disposed in
Laboratory.
the place provided
for disposal.
Punctured by
The use of lancet,
someone else’s
cotton, and capillary
lancet. Exposed to Transmission of blood-
5. tube in blood 1 4 4 Low
other people’s blood borne diseases.
chemistry laboratory
from cotton and
after use.
capillary tube.
When getting foreign
Air wash does not
6. object in the eye Eye irritation. 1 3 3 Low
work or often die
Wooden seating/
wooden benches are Less ergonomic
7. too old and many are chair. Symptoms of MSDs. 5 1 5 Medium
not sturdy/strong. Fell from the chair.

Place the goods/tools

Tool or item Injuring the person who
8. above the cabinet 5 1 5 Medium
dropped when taken. took the tool item.
(administration room).
Place a tool that can still Rust occurrence.
Enable chemical
be used and cannot be Material loss.
9. reactions between 4 1 4 Low
used as one. Time efficiency when
tools.
searching.
Do not know whether
The tool can not be
the tool is functioning
10. used properly or Tool damage. 4 1 4 Low
properly or not.
damaged.
3. Determining the Controls: Determining control Conclusion
in laboratory unit of OHS had been performed
but the determining control was still not effective. Risk assessment using HIRADC in laboratory unit
This was because the laboratory staff did not of OHS had various sources of hazard. There were ten
conduct former HIRADC; they only looked at potential hazards from laboratory activities.
risks that could be observed by the eye but not
The ten potential hazards may pose different risks.
thoroughly. The HIRADC method could help There were three categories of risk assessment, those
the existing determining controls and which risk were low-risk category, medium-risk category, and high-
could be prioritized to be controlled first. risk category. The results of the risk assessment had ten
Determining control applied a control hierarchy. risks. There were six risks with low-category, three risks
At low-risk category, determining control with medium-category, and one risk with high-category.
efforts could be done by elimination, that was
Determining control efforts performed followed
eliminating or separating equipment which was
a hierarchy of controls, those were elimination,
not usable and could still be used. Besides that,
substitution, engineering control, administrative control,
it was also performed administratively, such as
and the use of PPE.
the procurement of equipment and the placement
of first aid kit in accordance with PER.15/MEN/ Ethical Clearance: Taken
VIII/2008, Yellow Trash Bag (B3) was placed
beside the spirometer.4 Source of Fundings: Sponsored by University.

Laboratory staff supervised the practicum by Conflicts of Interest: There are not any of conflicts
controlling the provision of Safety Box. amongst the authors.
Laboratory staff administered the place of the
practicum, Laboratory staff proposed to procure a REFERENCES
pump so that the water could be supplied to the
laboratory room and the water wash functioned 1. AS/NZS 4360. 3rd Edition the Australian and New
properly and the recapitulation sheets existed Zealand Standard on Risk Management.
when the tools were used. Hence, if it did not Australia. Broadleaf Capital International Pty.
function properly, calibration could be done Ltd; 2004
immediately. 2. OHSAS 18001. Occupational Health and Safety
Risks with the medium category was controlled Management System Requirements; 2007
by administrative way such as Making rules or 3. Administrative and Bureaucratic Reform
SOPs for those who would enter the laboratory Minister (Republic Indonesia). Regulation of
area; printed and put in front of the entrance the Minister of Administrative and Bureaucratic
(prohibition of eating, drinking, using cellphones Reform Number 3 about Functional Position of
when not needed, the use of PPE, and the use of Educational Laboratory Institution and the Credit
tools). Add SOPs and rules in each lab chapter Numbers; 2010
in the General Practicum Guide. For example,
4. Manpower and Transmigration Minister (Republic
conditions that are permitted as a role model of Indonesia). Regulation of the Minister of
had to be in a healthy condition, not fasting, Manpower and Transmigration Number 15 about
and menstruate. It needed provision of bearings First Aid in the Workplace. Jakarta; 2008
on wooden chairs, repairment for the chairs that
were felt to be less sturdy such as the addition of 5. President (Republic of Indonesia). Government
nails and so on. Replacement also needed to be Regulation Number 50 about the Implementation
performed for the seats/chairs that were truly not of Occupational Safety and Health System.
feasible, and also applying and maintaining 5R Jakarta. 2012;2(7:3).
(Concise, Neat, Clean, Care, and Diligent). 6. Constitution (Republic of Indonesia). Law
Whereas the high-risk category was performed Number 1 about Occupational Health and
using elimination, that was MCB replacement Safety;1970
in the laboratory and performing routine checks 7. Vendamawan R. Chemical Laboratory
every month. Management. Semarang. Metana; 2015
889 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
DOI Number: 10.5958/0976-5506.2019.01690.5

Gluten-Free Diet: Positive and Negative Effect on Human

Health

Botagoz Kulushtayeva1, Maksim Rebezov2,3, Aidyn Igenbayev4, Yulia Kichko5, Nina Burakovskaya6,
Vladimir Kulakov7, Mars Khayrullin7
1
Shakarim State University of Semey, Semey, Kazakhstan; 2Ural State Agrarian University,
Yekaterinburg, Russia; 3V. M. Gorbatov Federal Research Center for Food Systems of Russian Academy
of Sciences, Moscow, Russia; 4Saken Seifullin Kazakh Agrotechnical University, Astana, Kazakhstan;
5
Orenburg
State University, Orenburg, Russia; Omsk State Technical University, Omsk, Russia; 7K. G.
6

Razumovsky
Moscow State University of technologies and management (the First Cossack University), Moscow, Russia

ABSTRACT
This article discusses the effects of a gluten-free diet on the human body suffering from various diseases
(celiac disease, autism, allergies). The article highlights both the positive and negative effects of a gluten-
free diet on the human body. In addition, the article provides a brief overview of gluten-free food
technologies (confectionery, bakery products).

Keywords: gluten, gluten-free diet, celiac disease, gluten-free foods, bakery products,
technology
Introduction The presence of specifical oats in a gluten-free diet
is
A gluten-free diet which is also known as the GFD questionable because it can be dependent on the cultivar
is a kind of diet that firmly eliminates gluten. While
gluten is the combination of different types of proteins
that are specifically found in wheat and all the products
related to wheat. It is also found in products like barley,
oats, and rye. Gluten is contained not only in all baked
products, wheat bread, pasta and macaroni products,
but also in all kinds of foods made with the addition of
wheat flour as a thickener - for example, semi-finished
products, sauces and ketchups. The term “gluten” is
applicable to a combination of simple prolamin (rich in
proline), called “gliadins”, and glutelin (rich in
glutamine), called “glutenins” the cereal proteins1.

Table 1: Content of gluten in different type of flour2

Protein content Gluten content
Type of flour
in 100g in 100g
Wheat flour 10 – 14 g 3.0 – 5.0 g
Barley flour 11 – 12 g 2.2 – 2.8 g
Rye flour 9 – 10 g 2 – 2.5 g
Oat flour 10 – 11 g 2 – 2.2 g
Millet 10 – 11 g 1.5 – 1.7 g
Dinkel wheat 10-15 g 0.3 – 1.0 g
890 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
DOI Number: 10.5958/0976-5506.2019.01690.5
of oat and also the repeated cross-contamination through
other gluten-containing cereals could be the reason of
this3. A specificity of gluten protein is that it has a very
low quantity nutritional as well as biological value.
Research says that the presence of grains that
specifically consist of gluten is not necessary for the
human diet. On the other hand, an unstable amount of
food, as well as an improper section of gluten-free
replacement foodstuffs, could be the reason for
nutritional deficiencies. Nutritional difficulties can be
prohibited with the help of accurate dietary education4.

Celiac disease (gluten-sensitive enteropathy) is a

disease caused by the inability of the intestine to digest
gluten from cereals. Celiac disease can occur in various
clinical forms, not always explicitly. In fact, there are
latent or hidden, clinically unexpressed and without
obvious symptoms, monosymptomatic forms or forms
with all intestinal and extraintestinal, clinical symptoms.
It is not yet determined the method of preventing the
development or treatment of celiac disease. Therefore,
only a gluten-free diet is the only therapy that can ensure
good health for people affected by celiac disease5,6.

Benefits of a Gluten-free diet: One of the biggest

benefits of a gluten-free diet is that it is helpful to
improve the level of energy at a higher rate. There
are various forms of gluten intolerance and also it has
numerous severities but those don’t have adverse effects
on the health of the human body. A gluten-free diet is Negative effects of a Gluten-free diet: According
also helpful to overcome the management of Autism. to research, it is estimated a gluten-free diet has not
Autism is a mental disorder that usually takes place in enough quantity of fiber in the overall diet so it can
the child of age two or less than that. For the treatment be the reason for constipation. Whole wheat and food
of this disorder, different therapies are recommended related to that has a huge quantity of gluten and these
and a Gluten-free diet is also suggested by the doctor7. are also the major sources of fiber. On the other hand,
gluten-free food consists of potato, tapioca as well as
According to research it is also observed that a
white rice that don’t have the adequate quantity of fiber
gluten-free diet is helpful to reduce weight however
as per the requirement of the human body. Diet consist
evidence for this claim is less but research says it
is useful to diminish weight. A gluten-free diet is of fiber, though indigestible, plays an essential role to
also helpful to absorb nutrients from the diet. By the reduce the level of constipation. It is also helpful for
absorption of nutrients, cellular activity of human body keeping the bowel movements regular as well as soft. To
is improved so it can be beneficial for the human body. prevent constipation while taking a gluten-free diet it is
Gluten is the special kind of protein that is linked with also very important to take the adequate quantity of food
the high intensities of swelling in the body that can be that is rich from the fiber.
the ultimate source of a high level of oxidative stress in
Gluten-free including different types of grains,
cells. The cells that are under oxidative stress can be the
reason for cancerous changes . 8 brown rice, quinoa as well as millet, fruits, vegetables,
seeds, and nuts don’t have an adequate quantity of fiber
Inflammation is the process that happens at the very so causes constipation11. According to research, it is
first stage of many cancerous variations. In this case, found that the people who are taking a gluten-free diet
the immune system might be inhibited instantaneously face the issue of nutrient deficiency12. There are lots of
and incapable to take care of cancerous fluctuations in gluten-containing foods including the bread; cereal, as
the very first stage. A gluten-free diet is also helpful to well as pasta and these, are richer form vitamins as well
improve the overall immunity of the body. There are as a mineral. These are also helpful to fulfill the demand
most of the diseases of heart and blood vessels that are of human freedom that is lacked in a gluten-free diet.
caused just because of the inflammation and Gluten-free So the fact is gluten-free forms of these kinds of foods
diet is helpful to reduce the inflammation so ultimately are less probable to be exhilarated. Just because of this
reduces the risks related to heart diseases9.
human body face the deficiency of B vitamins and iron13.
A gluten-free diet also helps to reduce allergies.
To evade such kind of deficiencies, there is a
Gluten bigotry also establishes externally, as repeated
need
occurrences that look like dermatitis that comes
to eat a balanced diet and also the person must
under
take a
multivitamin supplement . There are some undesirable
the common occurrences. Though these can be managed
with the help of application of contemporary anti-itch things that happen with the body while taking a gluten-
ointments, using an ointment is a much-recovered idea free diet. These include less gas, bloating as well as
to avoid the rashes in the initial place. Urticaria is the diarrhea. So by taking a gluten-free diet digestive system
type of allergy and also known as hives happens of human body is disturbed and within 6-8 months
commonly in individuals with gluten allergies. So these effects can be adverse than before15. So these are some
types of allergies can be controlled with the help of a negative effects of a gluten-free diet on the human body.
gluten-free diet. According to research, this diet is also
helpful to improve fertility and risk of spontaneous Technology and formulation of gluten free food
miscarriages can also be controlled by a Gluten-free products: Currently, the production of gluten free food
diet10. products, in particular confectionery products, is of
particular concern in worldwide. One of the methods of
Some other positive impact of a gluten-free diet production is to use in the formulation of flour of minor
includes fewer headaches as well as less joint pain. types as the main raw material.
Nutritional difficulties can be prohibited with the help of
accurate dietary education that can suggest either to take The patent16 describes the method of production
a gluten-free diet or not. However, a strict gluten-free of gluten free cake. The method involves following
diet can also have some negative effects on the human processes: churning margarine and granulated sugar
body and these are as follows. to
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 891
form a homogeneous mass within 10-15 minutes. Then Kozubayeva and Yegorova developed the gluten
adding eggs and salt and mixing for 20 minutes. Sifted free cakes from amaranth flour. Amaranth flour was
cornmeal and rice flour, starch and baking powder are mixed with corn or rice flour and added to the dough in
gradually added to the finished mass. Next, candied the form of a homogeneous mixture in the range
fruits and grinded lemon are added. The molding is from
carried out in the treated non-stick coating form. 5.0% to 25.0% of the total amount of flour according
Muffins are baked at 200 °C for 20-25 minutes and to the recipe. It was shown that the use of corn and
cooled to room temperature. The method of production amaranth flour in the ratio (10.0–12.5%): (90–87.5%)
allows to obtain gluten free cake with balanced amino or rice and amaranth flour in the ratio (15.0–17.5%):
acid composition and enriched with dietary fiber. (85.0–82.5%) allows to receive cakes products of the
standard quality. Developed new cakes contain lower
The authors17 developed the technology and
simple carbohydrates, but higher content of dietary
formulation of gluten free wafers. It comprises, wt.%:
fibers, easily digestible proteins and essential fatty acids
rice flour 12.0, buckwheat flour 48.0, sugar 18.4-19.0,
fat component 8.0-10.0, chicken egg 3.3 -3.7, invert compared with available on the market cakes20.
syrup Ethical Clearance: Not applicable
2.4-2.7, salt 0.3-0.5, drinking soda 0.3-0.5,
ammonium Conflict of Interest: Authors declare no conflict of
salt 0.1-0.3, potato starch 2.0 -3.0, drinking water up to interest
100. The ratio of rice and buckwheat flour is 1:4. The
proposed wafers is aimed expanding the range of gluten- Source of Funding: There is no funding source
free flour confectionery products and the possibility of
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DOI Number: 10.5958/0976-5506.2019.01691.7

Comparing Lower Grades and Higher Grades Astrocytoma in

Three Age Groups: by CD133 Antibody

Zainab Zahid Saadoon1, Huda Mahdi Al-Khateeb1, Khitam Abdul-Razak Alkhafaji1

1
College of Medicine, University of Baghdad; Iraq–Baghdad

ABSTRACT
Brain tumors are heterogeneous in nature and current studies reveal that aggressive behavior and recurrence
of the tumor are led by brain tumor stem cells (BTSCs) This stem cells compartment demands distinct
study to provide new therapeutics lines targeted against it. From the many markers that annotate BTSCs, is
CD133, the first marker used to identify BTSCs and regarded as the protein which confers resistance and
virulence of the tumor.
Aim of Study: Using CD133, to identify BTSCs by immunohistochemistry in paraffin sections of different
grades of astrocytoma, distributed in to three different age groups then, compared with each other. We
aimed to check the change in number of CD133-positive cells between grades and between ages, to
confirm that CD133 is a real representative for the actual increase in virulence across grades and ages.
Materials and Methods: 121 paraffin blocks are collected from the archives of specialty surgery hospital
in Baghdad and processed for immunostaining with CD133, then quantified to calculate number of positives
and comparing the results between different grades and different ages.
Results: We obtained increased in number of positives of CD133 by ascending from lower grades towards
higher grades in the three age groups; however, when we compared the same grade in between the 3
groups, we saw there was increase in expression from the children to the adult and then decrease in the
older, the adulthood show the most increase. The ascending manner of the expression is no longer
demonstrable across the age groups, that’s the older group show lower expression than the adults despite
being more virulent clinically. This mean that CD133 doesn’t stand alone as a candidate for
representation of the virulence in age group ≥50 years old.

Keywords: astrocytoma, grades, ages, CD133, virulence

Introduction stem cells (BTSCs), have the ability to proliferate and

self-renew expansively (3, 4). BTSCs are thought to
Most of the brain tumors develop the ability to resist
be the driving factor for intratumoral heterogeneity,
the treatment and/or the recurrence after surgical
cancer metastasis (5) and the cause for resistance to
removal (1), this demand more researches on the
radiotherapy/chemotherapy, so targeting them will lead
underlying causes. Emergence of the brain tumor stem
to tumor regression (3,4). Thus, the presence of distinct
cell (BTSCs) hypothesis (2), suggests that brain tumor
compartments in a tumor demand distinct identification
mass consists of heterogeneous cell populations and
and analysis, thereby treatments (6). CD133 represents
only a relatively small fraction of cells in the tumor,
an important cell surface marker of the BTSCs as the
termed brain tumor
capacity for tumor cell self-renewal and proliferation
exclusively resides in the minority CD133 cell fraction
Corresponding Author: (2)
. Moreover, CD133-positive BTSCs represent the
Zainab Zahid Saadoon cellular population that confers glioma radio resistance
College of Medicine, University of Baghdad; Iraq and could be the source of tumor recurrence after
Baghdad, Postal code 00964 radiation (7, 8, 9). CD133 is the first recognized member
Phone: 0700254259 of the prominin family, it’s a pentaspan
Email: [email protected] transmembrane glycoprotein,
894 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 894

with 865 amino acids and five transmembrane domains older “late adulthood and elderly” (50-80). Each
(10)
. From a clinical viewpoint, identification of BTSCs subgroup has 11 samples. Exclusion criteria: any brain
by CD133 has substantial implications clinically, as tumors other than astrocytoma, any secondary brain
these cells “need to be eliminated in order to offer tumors, recurrent brain tumors and any tumors that
long-term disease free survival” (11). The analysis of the treated previously by radiotherapy or chemotherapy were
BTSCs quantity by CD133 may provide novel all excluded. Samples were stained by H and E and
perception into patient prognosis that may then guide the immunostained by CD133. For immunohistochemistry,
aggressiveness of therapy (2) marker used was Polyclonal Anti- CD133 (MBS355164)
(My Biosource) Detection kit [including the secondary
In our study, we investigated the expression of
antibody and chromogen] is (Ready-to-use IHC/ICC kit
CD133 by BTSCs niches, in four grades astrocytoma in
(Biotin free), One-Step HRP Polymer anti-Mouse, Rat &
three age groups and compared the positives in between
Rabbit IgG with DAB) # MBS841593 (My Biosource).
the grades and ages, to correlate the expression change
For marker dilution, 1/300 was used diluted with Tris
with the grading of the tumor and with aging of the
Base Saline (TBS). Washing done with (TBS/TritonX).
patients. This comparison checked if they went parallel
Antigen retrival was done by Citrate buffer/Tween 20 at
with each other as the virulence increases, and checked
100 C°, for 15 min. Protein block and hydrogen
if the CD133 expression can be used to measure the
peroxide were applied then primary antibody; after that
prognosis and the virulence of the disease as long as the
detection kit with dab.
grading and the aging do, and to see if the grading has a
strong effect on its expression or/and if the aging has this Statistical Analysis: Eleven samples were counted for
effect. In this study, each group has four grades Ⅰ, Ⅱ, Ⅲ, each grade. Five random images of each sample were
Ⅳ except the group of older patients begins with grade counted by Aperio imagescope version 12.3.2.8013
Ⅱ, as we couldn’t find grade Ⅰ for this group. (Leica). The mean percentage of the number of
positives was calculated and reported as the mean then
Materials and Method eleven samples were counted as such and statistically
evaluated. The numbers were compared in between
121 Specimen blocks of brain tumors was collected the different grades in the same group and in between
from blocks archives of pathology department/Specialty the three groups for the same grade. Analysis of data
Surgery Hospital, after taking the consents from all was carried out using SPSS-25 (Statistical Packages
attributed institutes. Paraffin blocks specimens were for Social Sciences- version 25). The significance of
filtered according to inclusion criteria: primary difference of different means (quantitative data) were
astrocytoma, diagnosed according to WHO classification tested using Students-t-test for difference between two
2007, then categorized equally into the four grades of independent means or ANOVA test for difference
astrocytoma Ⅰ, Ⅱ, Ⅲ, Ⅳ (except the older group we among more than two independent means. Tukey’s test
couldn’t find grade Ⅰ for this age) and distributed into 3 used for calculating the significance between each two
age groups, (childhood (0-18), early and middle variables. Statistical significance was considered
adulthood (19-49 years) and whenever the P value was equal or less than 0.05.
Results

Table 1: Reveals the number of positive cells immunostained by CD133 antibody, among four
grades astrocytomas distributed in three groups children (<18y), adults (18-49y) and older (=>50y)

Astrocytoma Number of positive (NP) of CD133 immuno-labelling

P value
Grade Children (<18y) Adults (18-49) Older (=>50)
237195 ± 102974 604519 ± 132826
Grade I - 0.0001#
(91357-381996) (387079-865519)
484648 ± 140631 1000909 ± 340913 825748 ± 288176
Grade II 0.0001*
(307303-786582) (576147-1763458) (352546-1235639)
834223 ± 386767 1596705 ± 276710 1314618 ± 357221
Grade III 0.0001*
(416248-1590931) (1186986-2136518) (801179-1912214)
Conted…
1207776 ± 357821 2210875 ± 692743 1500973 ± 610768
Grade IV 0.001*
(838032-2006446) (1152678-2912634) (798325-3073683)
P value 0.0001* 0.0001* 0.003*
-Data were presented as Mean ± SD (Range)
*Significant difference among difference independent means using ANOVA test at 0.05 level.
#Significant difference between two independent means using Students-t-test at 0.05 level.

Figure 1: Comparing grades in children group reveals: increase in the no. of positivity whenever we go up
from lower grades towards higher grades of astrocytoma. All the grades show high significance in
changes when compared with each other

Figure 2: Comparing grades in adult group reveals: increase in the no. of positivity whenever we go up from
lower grades towards higher grades of astrocytoma. All the grades show high significance in changes when
compared with each other
Figure 3: Comparing grades in the group of older reveals: increase in the no. of positivity whenever we go up
from lower grades towards higher grades of astrocytoma (we couldn’t find grade Ⅰ for the older group). All
the grades show high significance in changes when compared with each other except the grade Ⅲ, Ⅳ show
no significance
Discussion the CD133 promoter was associated with the grade of
the tumor. Use of different procedure and different
We demonstrated: an increase in number of
CD133 antibody clones might explain the difference
positivity whenever we go up from lower grades towards
between our findings and the results obtained in other
higher grades of astrocytoma in all groups (children,
studies. Another explanation was use of different tissue
adult, and older groups), the number and intensity of
fixation methods. In other studies, cryosections were
cells expressing CD133 increases dramatically. All the
used to stain CD133, whereas we used formalin-fixed
grades show high significance in changes when paraffin sections. As CD133 represent the virulence of
compared with each other in the same group (p value the tumor (10, 16, 17), CD133 can be considered as
was very significant except for grade three and grade virulence index of astrocytoma across the grades. Many
four for the older group Fig 3). This goes with (12), who studies stated that the increased in tumor aggressiveness
stated the expression of CD133 increases with grades; and the bad prognosis go with increasing the grades (18, 19,
however, the latter conducted the study without 20)
. From our results, this may be attributed to the
segregating age groups for the grades and includes increase in CD133 expression concomitantly. Other
tumors other than astrocytoma like oligodendroglioma, studies stated that the aggressiveness and the bad
which did not exclude the bias of different histology; prognosis increase with aging (21, 19, 22, 23), however, the
in addition, it uses frozen section instead of paraffin latter studies differentiate between elderly and younger
sections. Our results also go with (13), however the latter through different virulent factors. In our study, when we
conducted the study on different types of glioma not compared expression of CD133 in between the three age
pure astrocytoma. Our results were inconsistent with (14) groups for the same grade, there was increase in
who describe no correlation between CD133 and grading expression from children to adult then decrease again in
of the glioma although the latter conducted the study by older (table 1). One study (24) stated that CD133
expression with immunofluorescence and without age expression has no relation with age, however the latter
groups and the study included secondary glioma in study analyzed CD133 gene by RT-PCR not by
addition to different glioma types. The results were also immunohistochemistry. All the grades demonstrate
inconsistent with (15), who proposed the percent of more increase in the adult group than the other two
expression was in opposite to the grades; however, groups (table 1, Figure 1, 2, 3). The expression decrease
they found the Methylation of again in the older group. In contrary to that, the
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Differences in Growth of Children with Autism and Normal in

Surabaya, Indonesia

Dewi Setyowati1, Budi Prasetyo2, Dominicus Husada3

Doctoral Program, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; 2Department of
1

Obstetrics and Gynecology, 3Department of Child Health, Faculty of Medicine, University of Airlangga
Dr. Soetomo Hospital, Surabaya, Indonesia

ABSTRACT
Background: Children with syndrome spectrum disorder wherein danger of a compromised dietary intake
and biological process standing that might impact growth over each the short and long run. Children and
youth with a disability were deemed to be at greater risk of obesity due to lower levels of physical activit y,
inappropriate behaviors associated with their disability, medication and related chronic health conditions.
Aim: To evaluate the growth status of children who were diagnosed with ASD in comparison with healthy
controls.
Method: This research was a cross-sectional analytic study using questionnaire instruments to guardians
and also direct measurements to respondents. The number of respondents for the group of children who
have autism was 30 children and normal groups of children as many as 60 children. The independent
variables in this study were children, autism and socio-economic, while the variables depend on body
weight according to age, height according to age and head circumference according to age. This data was
analyzed using the Mann Whitney U test.
Results: The results of the study of 30 children with autism and 60 normal children obtained a percentage of
children suffering from autism and normal children in the same good nutritional status as many as 76.67%.
Height according to age for children suffering from autism in normal conditions is 66.66% and normal
children are larger 83.33%, while for head circumference according to age children with autism and normal
children are 100% normal. After statistical tests using SPSS 23 with α = 0.05, p = 0.987 was found for
body weight according to age, p = 0.650 for height according to age and p = 1 for head circumference
according to age.
Conclusion: There was no difference in body weight, height, and head circumference according to age
between children with autism and normal so that it could be said that children who have limitations in this
case autism have normal growth like other children.

Keywords: Autism, Body weight, Height, Head circumference,

Growth.
Introduction social interaction and communication, yet as restricted,
repetitive or stereotypic behavior, with Associate in
Autism spectrum disorder (ASD) was a Nursing onset before three years older(1–3). Children
neurodevelopmental disorder defined by deficits in with syndrome spectrum disorder wherein danger of
a compromised dietary intake and biological process
standing that might impact growth over each the short
Corresponding Author:
and long run. The restricted body of revealed analysis
Dominicus Husada
addressing this concern has been contradictory and
Department of Child Health, Faculty of Medicine, inconclusive to this point(1,4). Children and youth with
University of Airlangga, Dr Soetomo Hospital, a disability were deemed to be at greater risk of obesity
Jl Prof Dr. Moestopo No.6-8, due to lower levels of physical activity, inappropriate
Surabaya, East Java, Indonesia behaviors associated with their disability, medication
Email: [email protected] and related chronic health conditions (2,5).
900 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 900

Centers for Disease Control and Prevention (CDC) means of detailed dietary evaluation and anthropometric
found that US boys were almost five times more likely assessment. The present study aimed to evaluate the
to receive an ASD diagnosis than girls, indicating that growth status of children who were diagnosed with ASD
approximately one in 42 boys is currently diagnosed in comparison with healthy controls.
with ASD (4). Patients with ASD may also suffer from
the leaky gut syndrome, which was caused by Method
inflammation of the intestinal mucosa and abnormal
bacterial overgrowth leading to a disorder of bowel The type of this research used analytic observational
motility (6–8). Two factors that were known to be risks research that used a case-control research design. This
in ASD and potentially influence growth were food study compared between the case group and the control
selectivity behavior and gastrointestinal health status. group. This research was conducted in the special
Selective dietary intake could play a significant role in school of Chakra, Agca autism and normal children
the growth status of children with ASD. Children with who were in Ceria, Diponegoro, and Darmahusada
ASD were more likely to have food selectivity and Children’s Kindergarten. The inclusion criteria for the
feeding issues resulting in challenging behaviors autism group in the study were autistic children who
surrounding food intake than their typically developing had not entered adolescence (women <12 years,
peers(1,2,9,10). Food selectivity continues to be highly men
reported in children with ASD and was simply defined <14 years) and guardians of autistic children who were
as the consumption of an abnormally limited variety of willing to become research samples, while the exclusion
food(1,11). This behavior affects food choices, which, in criteria were autistic children suffering from congenital
turn, could affect nutritional status and growth. For abnormalities and other diseases which affects growth
children with food selectivity behavior, a refusal to and autism children who were not in place when
consume one or more food groups is common, and measuring growth. In the control group had the inclusion
anxiety and tantrums could be associated with the criteria for normal children who had the same age range
introduction of new foods (1,12). as autistic children and guardians of normal children
who were willing to be the study sample, while the
Anthropometric measurements, including height, exclusion criteria were normal children suffering from
weight, and head circumference were an effective congenital abnormalities and other diseases that affected
method of evaluating dietary intake, growth status and growth and normal children who were not in place when
nutritional status in children with ASD(1). As noted, the measuring growth. The sampling technique used in this
effects of gastrointestinal symptoms and food selectivity study was using saturated sampling or census means
could lead to inadequate dietary intake, resulting in that the entire population was examined, this applies
abnormal anthropometric measurements (1,6,13). In some to the group of children with autism. However, for the
studies, no differences in BMI were reported between control group using the random sampling method. The
children with ASD and their typically developing independent variables in this study were children, autism
peers, whereas other studies have reported higher rates and socio-economic, while the dependent variable was
of underweight children with ASD compared to their body weight according to age, height according to age
typically developing peers. For these reasons, we chose and head circumference according to age. This data
to evaluate the physical status of children with ASD by analyzed using the Mann Whitney U test.

Result

Table 1: Characteristics of participant

Autism Normal
Characteristics
Frequency (n) Percentage (%) Frequency (n) Percentage (%)
Age (years old)
>2-3 1 3.33 1 1.67
>3-4 1 3.33 2 3.33
>4-5 6 20 7 11.67
Conted…
>5-6 12 40 24 40
>6-7 8 26.67 17 28.33
>7 2 6.67 9 15
Gender
Boy 21 70 42 70
Girl 9 30 18 30
Income
<Regional minimum wage (standard) 4 13.33 10 16.67
> Regional minimum wage (standard) 26 86.67 50 83.33
Nutrition intake based on recall food method 24
Deficient 24 80 8 13.33
Good 6 20 52 86.67

In this study, the study sample was boys less than fourteen years old and women less than twelve years old. In
this study, it is also known about the income of parents who have an average parent’s income above the Regional
minimum wage(standard) and nutritional intake for children because they were considered to provide an important
role in the growth of children. The method used in determining the amount of nutrient intake was using the 24-hour
recall food method so that it known the amount of nutrition eaten.

Growth: The growth of children in this study was grouped into three according to the main purpose of looking for
differences in growth which were classified into body weight, height and head circumference per age. The results of
the growth of autism and normal children could be seen in table 2.

Table 2: Distribution samples based on the growth of autism and normal children
Autism Normal
Characteristics p value
Frequency (n) Percentage (%) Frequency (n) Percentage 0 (%)
Body weight per age 8.33
Severe thinness 1 3.33 0 0.986
76.67
Thinness 2 6.67 5 15
Normal 23 76.67 46
Overweight 4 13.33 9
Height per age
Severe short 5 16.67 0 0 0.650
short 8 26.67 2 3.34
Normal 17 56.67 50 83.33
Tall 0 0 8 13.33
Head circumference per age
Normal 30 100 60 100 1
was no difference between the group of autistic children
and the normal ones. Body weight in both groups Our first hypothesis was that children with ASD
was Based on the by
dominated tablenormal
above, results,
it was explained head would have significantly
that there
height and lower anthropometric values,
Discussion
circumference of both groups also within normal limits. but this is no confirmed by our results. There was no
consensus
among previous research comparing the anthropometric the early childhood period. Children with ASD who
values of children with ASD and TD children found that exhibit food selectivity have been found to have sensory
prevalence of overweight and obesity was significantly sensitivity with concomitant aversions to specific colors,
higher among young children (2–5 years of age) and smells, temperatures, and textures, and preferences
adolescents (12–17 years of age) with ASD compared for energy-dense foods. Thus, children with ASD who
with the matched controls. However, for ages 6–11 years, exhibit sensory sensitivity may be predisposed to diets
no prevalence differences were found (13). Children with a limited variety that was high in energy-dense
aged foods and low in fruits, vegetables, and fiber, putting
2–5 years with ASD had more overweight and obesity them at increased risk for overweight and obesity(3,11–
and children aged 6–11 years had more underweight than 13,16)
.
theNHANES-matched cohort (14).
There was no evidence of statistical interaction
The exact reason why the weight would be between any of the dietary patterns and BMI z-score
unhealthy among children with ASD was not clear. with autism status (12). According to the anthropometric
Among schoolchildren of the age studied herein, growth data, there was no difference in body weight, height, and
was highly sensitive to the balance between energy head circumference according to age between children
intake and total energy expenditure. However, the with autism and normal. The results of the present study
energy intake estimates in children with ASD and TD
showed no significant differences between both groups
children were similar (13,15). Likewise, ASD and TD
regarding the contribution of energy intake from dietary
groups could present different patterns of growth
carbohydrate, protein, and fat in daily diets. Also, no
throughout the time life. In any case, although BMI was
significant differences between both groups in relation
an important indicator of a healthy weight, it was not
necessarily a good indicator of nutrient to energy, carbohydrates, and fats intake were observed.
status(7,13)respectively. We chose to fully evaluate the Furthermore, children with autistic disorder showed
nutritional and growth status of children with ASD and significant low protein intake and high fiber intake
their typically developing peers given the limited compared to healthy controls. Overall, the results of the
amount of data available regarding this topic, present study indicate that anthropometric measurements
incomplete work in prior datasets, and the conflicting of children with ASD are similar to those of healthy
results that have been reported to date peer controls. There were no significant differences in
measurements of height, weight and head circumference
Parents of children with ASD reported a greater
across participants in this study.
prevalence of food refusals based on the texture of food,
mixtures, brand, shape, and taste/smell than did TD
children. Contrary to expectations, a similar prevalence Conclusion
of food refusal based on temperature, foods touching
There was no difference in body weight, height, and
other foods, and the color was found between children
head circumference according to age between children
with ASD and TD children. Parents of children with
with autism and normal, so that it could be said that
ASD reported more reasons for food refusal, with over
one-third of parents reporting refusal based on three or children who have limitations in this case autism have
more characteristics of food (10). Gluten-free/casein-free normal growth like other children. Further research was
and lactose-free diets are followed by some children needed to determine the acceleration of growth in both
with ASD. Because children who adhere to these diets groups and the factors that influence it. Comprehensive
restrict all dairy products (9). physical and anthropometric assessment should be
completed for all children with ASD in a primary care
One such eating pattern, selective eating, was
setting as a baseline measurement to evaluate the need
characterized by a diet that lacks variety and has been
for referral for more specialized evaluation and potential
associated with inadequate consumption of foods low
intervention on a case-by-case basis
in energy density such as fruits and vegetables, lean
protein-rich foods, and foods high in fiber. Although not Ethical Clearance: The study protocol approved by the
uncommon in typically developing children, selective or Ethics Committee of Faculty of Medicine, Universitas
“picky” eating appears to be more prevalent in children Airlangga, Indonesia
with autism spectrum disorders and may persist beyond
Conflict of Interest: The author reports no conflict Symptoms: Nutritional Survey of Children with
of Autism Spectrum Disorder in Chongqing, China.
interest in this work. Nutrients. 2016;8(5):294.
Source of Funding: This study is done with individual 9. Bandini LG, Anderson SE, Curtin C, Cermak S,
funding. Evans EW, Scampini R, et al. Food Selectivity
in Children with Autism Spectrum Disorders
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7. Hill AP, Zuckerman KE, Fombonne E. 16. Siddiqi S, Urooj A, D’Souza MJ. Dietary Patterns
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DOI Number: 10.5958/0976-5506.2019.01693.0

Functional Outcome after Conventional Open Discectomy for

Patients with Herniated Lumber Disc: One Year Follow Up

Mohammed Hassan Razoki

Consultant Orthopaedic Surgeon, Department of Orthopaedics, College of Medicine, University of Kufa,
Iraq

ABSTRACT
Introduction: Lumber disc herniation is a common and frequently occurring disease. Conventional
discectomy is in use for decades, and it has got a curative effect for treatment of disc herniation which will
not respond to conservative treatment.
Aim of the Study: The current study aimed to evaluate the functional outcome after (12 month)
of
conventional discectomy for the management of patients with lumber disc herniation.
Patient and Method: A prospective study done in the period between October 2015 and February 2018 on
78 patients (40 males and 38 females) their mean age 37.6 years (range21-65) was diagnosed with sciatica
caused by single level lumber disc herniation (LDH) and underwent open discectomy. Each patient was
followed up for one year regarding their functional outcome, using the Oswestry disability index.
Results: The means of the total oswestry low back pain scoring scale after 6 months, and 12 months of
management were significantly decreased compared to mean before management (60.7% versus 38.1%,
P=0.004; and 60.7% versus 24.7% respectively).
Conclusion: Conventional open discectomy is still a good method for treatment of lumber disc herniation.

Keywords: Lumber disc herniation, conventional discectomy. Oswestry Disability Index

Introduction Surgical discectomy gives earlier relief of
symptoms, enabling patient to return to their work and
Lumber disc herniation (LDH) is the most common
other daily activities more rapidly.(3)
diagnosis among the degenerative abnormalities of
the lumbar spine (affecting 2 to 3% of the population, Conventional classical operation (laminectomy/
and it is the principle cause of spinal surgery among laminectomy with discectomy) is in use for decades;
adult population. (1).. The natural history is generally however in 1977 microdiscectomy technique was
favourable, with improvement of symptoms in 75% of performed for lumber disc herniation.. (3)
patients after 4 weeks (2).Although most patients relieved
from symptoms without surgical treatment, there is The advantage of open discectomy is that there
a consensus for operating on selected patient with is more accumulated experience with it, no additional
persistent radicular pain after 2-6 months. (3) endoscope or microscope is needed, and the duration of
learning curve and of the operation is shorter.. (4)

The last decade has seen an evolution of minimally

Corresponding Author: invasive spine surgery with
Mohammed Hassan Razoki
Consultant Orthopaedic Surgeon, new technological developments. Minimally
Department of Orthopaedics, invasive spine surgery is thought to decrease
College of Medicine, University of Kufa, Iraq postoperative pain and allow quicker recovery by
Email: [email protected] limiting soft tissue retraction and dissection. Advances
in microscopy, tissue
905 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 905

retractors, and specialized instruments have enabled Scoring System: The scoring system that had been used
surgeons to perform procedures through small incisions. to evaluate the functional outcome of the patients in
As with the open approach, the goals of the minimally this study is the Oswestry Disability Index (ODI) which
invasive approach are to adequately decompress the is also known as (Oswestry Low Back Pain Disability
involved neural elements, stabilize the motion segment, Questionnaire). (10)
and/or realign the spinal column according to the needs
of the individual patient (5) The score was calculated for each patient in the
study (in regard to all of its variables: pain intensity,
In 1997 tubular retractors and the endoscope was personal care, lifting, walking, sitting, standing,
first introduced and later adapted to incorporate the sleeping, sex life if applicable, social life and travelling)
operative microscope (6,7). These techniques allow for at the preoperative period (the day before the surgery),
enhanced visualization through a small skin incision, and recalculated during the periods of the follow up
and they cause minimal disruption to the posterior which had been selected in the current study (6 months
muscles. As a result, patients spend less time in the and 12 months) postoperatively.
hospital and are able to mobilize quicker, ultimately
Surgical Procedure: Preoperatively lumber spin MRI
leading to high patient satisfaction and significant cost and AP and LAT plain X ray of lumbar spine were
savings. (8,9) taken. Informed consent was taken from all the patients
included in this study. Surgery was done under general
Several recent studies have compared conventional
anaesthesia, patient placed in a prone position with
open discectomy with microdiscectomy to find if
the abdomen free to reduce the intraoperative venous
there are any significant differences by using either
bleeding. The proper level was determined by
method. In this study we want to find the functional
fluoroscopy. A 5-8 cm.mid line incision and facia
outcome after one year for patient who underwent
incision done, and the paravertebral tissue retraced
conventional open discectomy. In future we hope when using deep retractors. In most cases flavectomy and
the operative microscope become available that we will arcotomy of the lamina above the disc level was done.
do comparative study for the functional outcome after Carful mobilization of the dural sac and the nerve root
doing open discectomy versus microdiscectomy. medialy before evacuating the herniated disc. This might
involve entering the disc space, or just removing a free
In this study we used the Oswestry Disability Index
sequestrated disc fragment (sequestrectomy).After
(ODI) (10) (also known as the Oswestry Low Back Pain
checking the epidural space, the layers were
Disability Questionnaire) to evaluate the functional
appropriately closed.
outcome postoperatively. It is extremely important tool
that researchers and disability evaluators use to measure Follow up: All patients discharged from the hospital
a patient’s permanent functional disability. The test is after 2-3 days with instruction of free movement in
considered the ‘gold standard’ of low back functional bed with assisted walking for few steps until day ten
outcome tools where the stitches were removed. After 2-3 weeks they
can return to their light daily activities. The follow up
Patient and Method continue and after six months all the patient were re-
evaluated using the Oswestry disability score. The same
Patient and Study Design: Seventy eight patient (40 thing done for all the patients after 12 months. All the
males and 38 females) diagnosed with sciatica caused data about the patients and the results of the ODI were
by lumber disc herniation (LDH).conventional open analysed accordingly.
discectomy done for them during the period from
Statistical Analysis: The data analyzed using Statistical
October 2015 to February 2018. Each patient was
Package for Social Sciences (SPSS) version 25.
followed up for one year after the surgery regarding t The data presented as mean, standard deviation and
functional outcome. ranges. Categorical data presented by frequencies
and percentages. Paired t-test (two tailed) was used to
The patients included in the study had single level
compare different ODI scores pre and postoperatively
disc herniation with radiculopathy proved by MRI, with
among study groups. A level of P – value less than 0.05
no history of previous back surgery.
was considered significant.
Results Total Oswestry Low Back Pain Scoring Scale:
Comparison of total ODI Score before operation and
The total number of patients in this study was 78. after; 6 months, and 12 months of management (table 2).
All of them were diagnosed as having lumber disc It shows significant improvement after 6 and 12 months
herniation and treated by conventional open discectomy. from the operation, 60.7% versus 25.2 %, (P=0.001);
and 60.7% versus 21.4% (P=0.001) respectively).
The general characteristics and variables regarding
the patients are shown in table (1). The age was ranging
Table 2: The results of ODI preoperatively,
from 21 to 65 years with a mean of (37.6) years and
6months, and 12 months postoperatively
standard deviation (SD) of ± 7.3 years. The patients
aged ≤ 50 years were (67) (85.89%), and those above ODI% P
variable
Mean ± Std. Dev Value
(50) were (11) (14.10%). Females were 38 (48.7%) and
males were 40 (51.2%). For occupation; 44.9% were preoperatively 60.7 ± 5.62 0.001
housewives, 19.2% free jobs, 14.15%employee, 8.89% 6months postoperatively 25.2 ± 10.42 0.001
farmers, 7.7 %retired, and 5.1%drivers. The table show Reduction of
35.5
ODI/6months
that the right sided disc herniation is little bit more
Preoperatively 60.7 ± 5.62 0.001
than the left. It also shows that 50% of the patient has
12months
herniation at L4/L5 level, and about 45% have 21.4 ± 3.69 0.001
postoperatively
herniation at L5/S1 level.
Reduction of
39.3
ODI/12months
Table 1: General characteristics and variables of the
patients Discussion
Variable No. = (78) Percentage % The prevalence of symptomatic herniated lumber
Age(21-65) disc is about 1-3%in Finland and Italy. About 19/27%
Mean(37.6) of people without symptoms have disc herniation on
≤ 50 67 85.89% imaging.(11)
> 50 11 14.10% Lumber disc herniations are the most common
Gender causes for working –age individuals to undergo lumbar
Male 40 51.28% spine surgery. (12).
Female 38 48.71% The surgeon according to his training and his
Occupation experience can chose (for surgical treatment of lumber
Housewife 35 44.9% disc herniation) any method like microdiscectomy,
Free job 15 19.2% endoscopic microdiscectomy or the classical operation
(laminectomy/laminectomy with discectomy).
Employee 11 14.1%
Farmer 7 8.89% Several questionnaires are available to help measure
Retired 6 7.7% the functional status of a patient, the ODI is the most
commonly used outcome-measure questionnaire for low
Driver 4 5.1%
back pain in a hospital setting (13).
Side
Right 42 53.84% As seen from our results using the ODI there was
a great improvement in the functional out come after
Left 36 46.15%
conventional open discectomy. Statistically there was
Level significant decrease in the score (P < 0.05).
L5/SI 35 44.87%
L4/L5 39 50% Most of the studies shows a significant improvement
of the ODI postoperatively, but there was no significant
L3/L4 2 2.56% differences whether we use conventional open
L2/L3 2 2.56% discectomy or microdiscectomy (1,3,4,14,15).
Cagatay et. al. (4) in their paper on 519 patients there in no particular advantage of either technique in
compare the outcome of functional results between terms of functional outcome. But they also found that
patients treated by open discectomy and others treated there was significant lower recurrent disc herniation and
by microdiscectomy, concluded that “the long term higher reduction of leg pain in case of microdiscectomy.
results in both groups were similar and the choice of
either method depend on the experience”. Luis et. al. (1) concluded that the clinical results were
similar after 2 years by using either surgery. They were
Xiaosheng et. al..(14) also compare the two methods; in favor of early surgery because recovery is faster and
they found that both methods obtain the same surgery is economically favorable since it enables early
satisfactory results. The advantages of microdiscectomy return to work.
are that it is minimally invasive method, with less blood
loss, short time, short hospitalization, with fewer George et. al. (16) did analysis of results of surgery of
medical expenses. over 39.000 patients and found that all the patients had
79% good/excellent results, and none of the
Andreas et. al... (3), also found no significant operative
difference in the functional outcome between two procedures gave a different outcome.
methods.
Table (3) is to compare between different studies
Kovačević et. al. compared standard lumber
(15)
regarding age and gender of patient who underwent open
discectomy with microdiscectomy and concluded that discectomy.

Table 3: Age and gender of different studies

Study Total No. Age (range) Mean age Male Female
Present study 78 21-65 37.6 40 (51.28%) 38 (48.77%)
Cagatay et. al. (4) 276 27-67 44.8 176 (63.8%) 100 (36.2%)
Xiaosheng et.al. (13) 225 15-79 46 127 (56.44%) 98 (43.55%)
Kovačević et. al. (14) 111 17-75 44.9 57 (51.35%) 54 (48.64%)
The table shows that the mean age group in jobs. (4,11,14,15). Yet our study shows the highest percentage
this of female patients among other studies. The explanation
study was 37 years while in the other studies was about for that is that about 50%of housewives in the group are
45-46 years. Our study also shows that the number “farmers” coming from rural areas around city of Najaf.
of patients above 50 years were(11) and represent
(14.10%) of the whole group. These results give us Regarding the levels predominantly affected,
an idea about epidemiology of lumber disc herniation our study shows that 94.87%of the cases have disc
in the population, were this disease is less common in herniation at L4/L5 and L5/S level. The same findings
older people. Jo Jordan et.al. (11), found that the highest seen by Jo.Jordan et al(11)., Cagatay et al. (4), and dauyo
prevalence of lumber disc herniation is among people et.al. (17)where the results where 95%, 93.47%, and 95%
aged 30-50 years. respectively, with L4/L5 more predominant.

Daoyou et. al. (17) concluded that a decrease of Conclusion

LDH with aging occur in the elderly. This is because the
volume and inflammation of the nucleus gets lesser since Conventional lumber open discectomy is still a good
degeneration lead to atrophy of the nucleus with the method for treatment of lumber disc herniation.
aging. Thus, the pressure from the nucleus will become
Conflict of Interest: No conflict of interest
gradually less, with the result being lower incidence of
annulus injury and occurrence of lumber disk herniation, Source of Funding: None
especially after 80 years old (17).
Compliance with Ethical Standerds: Informed consent
In almost all the studies the males are predominantly was obtained from all individuals participant included in
affected by LDH than females and this is probably the study.
because males involved in more “hard working” types of
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Clin. Intery Aging 2013:8:1047-1050.
ME. Minimally. Minim Invasive Neurosurg.
2007;: p.
160–162.
DOI Number: 10.5958/0976-5506.2019.01694.2

Early Complications Following Bipolar Hemiarthroplasty as

Primary Treatment for Displaced Femoral Neck Fracture in
Elderly Patients

Mohammed Hassn Razoki1, Adnan Essa Elkelaby1

1
Department of Orthopedics, College of Medicin, University of Kufa

ABSTRACT
Femoral neck fracture is one the most important traumatic event in elderly patients. The objective of this
study is to assess the incidence of early complications following bipolar hemiarthroplasty for management
of displaced femoral neck fractures in elderly patients.
Patients and Method: This is a prospective study of 60 patients 60-90 years old (37 female and 23 male)
with
displaced femoral neck fracture who underwent bipolar hemiathroplasty with a follow up period ranged
from
12-22 months. Several variables including age, gender, medical comorbidities, type of
fracture,complication
mortality and Harris Hip score were assessed.
Results: There were four cases of infection, two cases of dislocation, eighteen cases anterior thigh pain,
two cases of DVT and two mortality. The average HHS decrease with increasing age of the patients. There
was no significant intraoperative complications but there was postoperative complicaions.
Conclusions: Bipolar hemiarthroplasty through posterior approach seems to be a good option for primary
treatment of displaced femoral neck fractures in elderly patients with few complications.
Keywords: Hemiarthroplasty, femoral neck fracture,
complications.
Introduction Email: [email protected]

Femoral neck fracture is one of the most important

traumatic event in the elderly, because of its high rate
of complications (1). Femoral neck fractures occur most
frequently in elderly female patients following fall from
standing height and may be associated with
osteoporosis. Undisplaced femoral neck fractures
account for 15% of these fractures in elderly and are
usually treated with internal fixation. There are several
surgical options for displaced femoral neck fractures
with regard to patient’s age, functional status and
cognitive function. In this group of patients, reduction
and internal fixation is associated with significant
complications. Therefore, hip arthroplasty is the
treatment of choice. The appropriate

Corresponding Author:
Mohammed Hassn Razoki
Department of Orthopedics, College of Medicin,
University of Kufa, Iraq
intervention was selected based on individualized patient
assessment and planning(2).

In United Kingdom, over 300 000 patients are

admitted to hospital with fragility hip fractures every
year (3). The incidence of these fractures is 2-3 times
more in females as compared to male population (4). Hip
fractures account for around 20% of the surgical
fractures. Femoral neck fracture account for
approximately 50% of all fractures of the hip region (5).

The incidence of proximal femoral fractures tends to

increase among the elderly as mean lifespan continues to
increase. Hip fracture rates are highest in Northern and
Central Europe, moderate in North America, and at the
lowest in south Asia and Africa. For each decade
after
50 the risk of hip fracture double and the
worldwide
incidence is predicated to rise from 1.7 million in 1990
to
6.3 million in 2050 (6). Hip fractures are associated with
30 % mortality at one year and a profound temporary,
sometimes permanent impairment of independence and
quality of life (3, 7, 8).v
910 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 910

Patient and Method Blunt dissection will usually remove the

trochanteric bursa. Internal rotation of the hip makes
This prospective study conducted on 60 patients (37 external rotator more stretch and obvious and displaces
female and 23 male) with displaced intracapsular their insertion away from the sciatic nerve. The external
femoral neck fracture (Garden type 3 and 4), all treated rotator and piriformis tendon now tagged with a stay
by bipolar himiarthroplasty from January2016 to sutures so that they well be re-attached at the end of
November 2017. The follow up period ranged from 12- the procedure. After that, they are transected near their
22 months. insertion and reflected backwards to protect sciatic
nerve.
They were 60 - 90 years of age with mean of (74.2).
Thirty-nine patients have right hip fracture (65%), in The capsule now seen and incised longitudinally
twenty-one patients the left hip was involved (35%). or mainly by T-shaped incision exposing the fractured
femoral head and neck.
The time interval between the injury and bipolar
hemiarthroplasty varies from two to seven days.fracture The fractured head then removed by corkscrew with
occure in48 patient after fall while 7 sustained RTA and transecting ligmentum teres and measured to determine
5 had twisting injury. the appropriate size.

After that, the femoral canal preparation performed.

Method Then filling the femoral canal by cement using cement
The patients were investigated for fitnes for gun and then insert the cemented prosthesis and waiting
anesthesia. for setting and finally reduction done.

Assessment for the general health of the patients Assessment of the size of prosthesis and the
stability of hip then done. Suturing in layers (joint
with medical consultation if needed.
capsule, external rotator, piriformis, fascia lata, skin)
Analgesia and enoxaparin (LMWH) in prophylactic with suction drain and finally dressing.
dose was given to the patients. LMWH stopped 12 hours
before surgery and return back after 12 hour.

Informed written Consent was taken.

Surgical Technique: All patients were operated

under spinal anesthesia and given 1-gram ceftriaxone
intravenously one hour before skin incision. All patients
were operated through posterior Moor approach by the
same surgical team.
Fig. 1: Preoperative x-ray of the hip
The patient was securely fixed in the lateral
decubitus
position with the operated side uppermost.

The skin incision starts 10 cm from the PSIS and

directed laterally and distally posterior to the posterior
edge of greater trochanter and extends for 10 or more
cm, parallel to the shaft of femur.

The fascia lata was exposed and incised in line

with skin incision. Gluteus maximus muscle splitting in
proximal incision then occurred.

Retraction of the gluteus maximus muscle reveals

the back of greater trochanter overlying by trochanteric
bursae. Special care is taken in order to not injure the
sciatic nerve. In most cases, the sciatic nerve have to be Fig. 2: Postoperative x-ray of the hip
identified and protected.
After Care: The patients instruct to lie supine with was observed. The duration of surgery ranged from 45-
abducted and externally rotated lower limbs. 60 minutes (the mean is 52.5), post-operative length of
An antibiotic regimen with ceftriaxone 1gm IV once stay 2-4 days, In 1 year follow up we have :
daily for 3 days then change to oral antibiotic in form Four cases had wound infection (6.67%) discovered
of Augmentin 1000 mg twice daily for 7 – 10 days, low at time of stiches removal
molecular weight heparin (enoxaparin 4000 IU once
daily) for thirty days in addition to analgesia in form Three cases was superficial infection responding
of paracetamol vial 1g three times daily and tramadol well to parenteral then oral antibiotic therapy and one
ampoule on need administered postoperatively. was deep infection need surgical debridement and
extraction of bipolar and finally received THR.
We advise patient to start movement of normal limb
and ankle movement of operated limb as early as Two cases had posterior dislocation (3.33%).
possible and as tolerated in addition of calf massage by Eighteen cases had anterior thigh pain (30.00
relatives, elastic stocking. Patients were mobilized on
%)
the second postoperative day using a walker frame. AP
which was mild to moderate.
radiograph of the operated hip performed after
mobilization (second postoperative days), 14 days Two cases had DVT (3.33%) which treated
postoperatively (at time of stiches removal), and then conservatively.
as indicated. The suction drain removed after 24-48.
Two cases of death (3.33%).
The patient continued on partial weight bearing for
4-6 weeks then turned to full weight bearing Table 1: Harris Hip Scores of Patients in the studied
accordingly group

Fellow up: The patients were followed for any Harris Hip Scores Pt. %
complication at second week, fourth week, second Excellent (90-100) 11 18.33%
month, six month and 1 year. Good (80-89) 37 61.67%
All data were collected and analyzed according to Fair (70-79) 7 11.67%
Harris Hip Score(9) Poor (< 70) 5 8.33%

Results
There were 60 patients in our study. their age varied
from 60 to 90 years old (mean 74.2).Sex distribution
showed female predominance (37 female and 23 males)
forming 61.67% and 38.33% respectively.
There was at least one comorbid condition in 36
patients. Cardiovascular disease was the most common
comorbid condition in our patients.
In our study there was not any significant
intraoperative complications.17 patients needed blood Fig. 3: Relationship of HHS and age of the patient
transfusion intraoperative while 11 pt. receive blood in
the ward (1 unit of blood). No intraoperative This figure show the decrement of HHS with
mortality increasing age of the patients.
Table 2: Show the relationship (P-value) between complications and age, gender, Type of fracture,
medical comorbidities, and blood transfusion
Discussion We had 2 case of posterior dislocation in our
studied group (3.33%) which happened 6 – 8 week
Elderly ambulatory patient with Garden’s type
postoperatively when patients start full weight bearing
III and type IV, better treated by prosthetic head
and both cases treated by open reduction under spinal
replacement or total hip replacement. This is because
anesthesia.
old people must be active and got up without delay to
prevent complications. (10,11,12). For the same complication, Rajak et al. (22),Mandanat
et al. (23). and Kim et al(24). reported 3%,5.6% and 3.8 %
Using a prosthesis in a fresh femoral neck fracture
respectively.
allows immediate weight bearing and returns of elderly
patients to activity and help to avoid complications of This dislocation rate may be attributed to
recumbency. It also eliminates avascular necrosis and compromising the strong posterior capsule during
nonunion as a complications of femoral neck fractures. posterior Moore approach making the hip more
It also reduces the reoperation rates compared to internal vulnerable to dislocation. There was insignificant
fixation. (13,14). relationship between dislocation and our comparable
The complications of persistent pain and protrusio variables.
acetabuli with unipolar hemiarthroplasties have led There were 18 cases of anterior thigh pain (30.%)
many surgeons to choose a bipolar system. The lack which was mild to moderate (according to simple pain
of biological fixation of the non-textured stem inserted
score)(9), they respond well to rest or simple analgesics
without cement may cause long-term thigh pain. The
in form of paracetamol or NSAIDs.
biarticular design of the bipolar system is thought to
be associated with less acetabular wear than unipolar Also Rajak et al. (22). reported 30% cases of pain
prostheses. A suggested but unproved advantage of the of which 20% mild pain and 10% moderate pain,
bipolar design is improved stability of the prosthesis and whileVincent et al (25). reported the 24.6% rated as
resistance to dislocation. (15,16). moderate to severe in their series. We found significant
relationship between anterior thigh pain and gender P-
In this study, we had 4 cases of surgical site
value (0.0171), while there was insignificant relationship
infection(SSI) (6.67%), three superficial infection
between anterior thigh pain and other variables.
treated conservatively. The fourth was deep refractory
infection not responding to conservative management, it We reported two cases of DVT (3.33%).while Lee
ended with THR., et al(26). reported incidence of (2.7%). Mazen et al(27).
reported higher incidence which was(11.8%). We found
Shah et al. (17)., Lu-Yao G et al.(18), and Saberi.(19)
significant relationship between DVT and age of the
reported incidence of SSI as 0.1%, 1.7% and45%. In this
patients P-value (0.0009), while there was insignificant
study, we found that there was significant relationship
relationship between it and other variables.
between SSI and age of patients P-value (0.0007),
presence of DM P-value (0.0004) and receiving blood There were two cases of death, which represent
transfusion P-value (0.0269).) . Kaye et al(20). in their about (3.33%). One of them died after three weeks of
article (the effect of increasing age on the risk for operation and the other one died six weeks
surgical site infection) proved that increasing age in postoperatively.
adult has often been identified as a risk factor for SSI.
Rajak MK et al. (22). had no mortality in their series
In their study Lu-Yao G et al. found that patients of 30 patient while Rödén M et al (28) reported (9.3%)
(18)

with DM had a higher SSI than those without DM (5.6% mortality in their 100 patient.
vs. 3.7%) Kim et al (21) found significant relationship
between allogeneic blood transfusion and SSI following We found significant relationship between mortality
hip and knee arthroplasty. The incidence was 2.88% vs and type of fracture P-value (0.0056), while there was
1.74% for the transfusion and non-transfusion group insignificant relationship between it and other variables.
respectively) On the other hand, we found no
relationship between infection and each of gender of pt., The mean Harris Hip Score result in our study was
type of fracture and presence of comorbidities other than 80.6 which was comparable to other studies such as
DM. that of Rajak et al. (22) (83.1) and Mouzopoulos et al) (29).
(83.7. HHS decrease with increase ages of the 8. Leu1 TH, Chang WC, jeff chien-fu lin J C F et
patients al. Incidence and excess mortality of hip fracture
as seen in this paper. in young adults: a nationwide population-based
cohort study leu et al. bmc musculoskeletal
Conclusion disorders (2016) 17:326.
Bipolar r hemiarthroplasty through posterior 9. Harris W H.Traumatic arthritis of the hip after
approach seems to be a good option for primary dislocation and acetabular fractures: treatment
treatment of displaced femoral neck fractures in elderly by mold arthroplasty. an end-result study using
with few complications. a new method of result evaluation. JBJS. 1969
jun;51(4):737-55.
Conflict of Interest: None
10. Moroni A, Hoque M, WaddellJP, et al. Surgical
Source of Funding: None
treatment and management of hip fracture
Ethical Clearance: Informed consent was obtained patients. Arch Ortho Trauma Surg. 2014;
from all individuals participant included in the study. 134(2):277-81.
11. Tanous T, Stephenson KW, Grecula MJ. Hip
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DOI Number: 10.5958/0976-5506.2019.01695.4

Assessment of the Anterior Talofibular Ligament(ATFL)

Thickness in Chronic Stroke Patients by Ultrasound

Mohammed Hassn Razoki1, Nada Rida Alharis2, Haider Kadhim Hussain2

1
Department of Orthopedics, 2Department of Radiology, College of Medicin, University of Kufa, Iraq

ABSTRACT
Stroke is one of the commonest diseases affecting people world - wide. Spastic equino varus foot is one
of most common disabling deformities observed among hemiparesis patients. The aim of the study is to
compare ATFL thickness on the affected and unaffected sides of chronic stroke patients with that of healthy
individuals using ultrasonography.
Method: Comparative case-control study carried out between October 2017 to September 2018. There
were
77 chronic stroke patients (46 males and 31 females) , matched 154 healthy individual (90 males
and 64
females).
The thickness of the anterior talofibular ligament(ATFL)was measured using
ultrasound.
Results: The mean thickness of ATFL in stroke cases was significantly higher (2.74 ± 0.25 mm) than the
mean thickness of ATFL in control group (2.34 ± 0.22 mm) , while the mean ATFL thickness was
significantly higher in both affected and unaffected sides in stroke cases than mean thickness in the control
group. Within the stroke cases the mean ATFL thickness was significantly higher in the affected than
unaffected side, while in control group, there was no significant difference between both sides.
Conclusion: Chronic stroke patients had thicker ATFL on the affected side than unaffected side & both
sides
were thicker than the group healthy control.

Keywords: Ultrsonagraphy.Anterior talofibular ligament. Equniovarus.

Strocke
Introduction Department of Orthopedics, College of Medicin,
University of Kufa, Iraq
Anterior talofibular ligament (ATFL)is one of the Email: [email protected]
most biomechanically important ligament of ankle, it is
also the most frequently and often first to be injured as a
result of abnormal inversion stress(1). The average width
of ATFL is 7.2 mm and average length is 24.8 mm long
(2)
. The anterior talofibular ligament limits the anterior
displacement of the talus and plantarflexion of the ankle.
Only in plantarflexion the ligament comes under strain(3).

Following stroke patient may develop

hemiparesis,
which can have a profound effect upon walking

Corresponding Author:
Mohammed Hassn Razoki
ability(2,4). Spastic equinovarus foot (SEVF) is one of the
most common disabling deformities observed among
hemiplegic patients. SEVF deformity has four main
causes(5,6). The first is spasticity of the calf muscles
(soleus, gastrocnemius, tibialis posterior, flexor
digitorum and flexor hallucis longus muscles) ,
responsible for SEVF in the stance phase of gait. The
peroneus longus and brevis muscles may also be spastic
(often with clonus), but such spasticity is useful to limit
the varus and stabilize the ankle. Secondly, the spastic
muscles have a tendency to remain in a shortened
position for prolonged periods, which, in turn, results
in soft-tissue changes and contractures, leading to a fixed
deformity. Thirdly, weakness of the ankle dorsiflexor
muscles (tibialis anterior, extensor digitorum and hallucis
muscles) as well as the peroneus longus and brevis
muscles is often emphasized by triceps spastic co-
contraction and/or contracture. The weakness also affects
the triceps surae muscles, leading to a lack of
propulsion at the end of the stance phase of gait.
916 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 916

Lastly, an imbalance between the tibialis anterior and the Exclusion Criteria
peroneus muscles leads to varus of the hind-foot in
theswing phase, as peroneus activation must compensate for 1. Previous botulinum toxin injection to
gastro-
physiological varus positioning related to contraction soleus muscles
of
the tibialis anterior. In such a case, the foot will be placed 2. Event of post stroke period ankle injury.
in an unstable varus position during the swing phase and
3. Fixed ankle contracture.
at the beginning of the stance phase(7). The incidence
of
equinovarus deformity of the foot in adult stroke patients 4. Previous surgical intervention of the lower limbs.
has been reported to vary between 10% and 20% (2).

Equinovarus deformity can increase the chance of Method

fall,as the feet tend to drag over the floor during swing All the patients and control group underwent gray
phase(8). Recovery of walking ability by addressing
scale sonography to measure thickness of anterior
the ankle-joint deformity helps patients with stroke
talofibular ligament (ATFL) using a linear probe (7 - 12
to regain independence in daily life, and is one of the
MHz GE VOLUSON E8 ultrasound machine) and was
main rehabilitation training goals(9). Fortunatly, ankle-
foot orthoses have been used successfully to correct done by same radiologist.
equinovarus deformity after stroke(10). However little Measurements was taken as the patient in a supine
was written about the effect of equinovarus deformity
position with the ankles in neutral or slight plantar
on ATFL in patient with post stroke hemiplegia. The
flexion. A longitudinal image of the ATFL was scanned
aim of this study is to compare between the anterior
with the transducer placed in a slightly oblique direction
talofibular ligament (ATFL) thickness on the affected
and unaffected sides of chronic stroke patients with that from the anterolateral aspect of the lateral malleolus to
of healthy individuals using ultrasonographic study. the peak of the talus.

The hyper echogenicity of the two bony landmarks

Patients and Method made them easy to be identified the ligament. The normal
Patients and Study Design: This comparative case ATFL was depicted as hyperechoic bundles on
control study was carried out on 77 patients from sonography. ATFL thickness was measured halfway
October between the two bony landmarks of the ankle. All
2017 to September 2018. There were 77 chronic stroke sonographic measurements were taken in the plane
patients, matched with 154 healthy individual. The perpendicular to the long axis of the ligaments for
selection of patients (chronic stroke patients) and control standardization and reproducibility of the measurements.
group was done according to inclusion and exclusion The thickness of the ligaments was measured two times,
criteria, where chronic stroke is a period starting six
and the mean values were recorded as shown in figure
months after initial stroke. All patients and controls
(1).
were referred from orthopedics and rehabilitation unite
after fully diagnosis of chronic stroke patients by clinical
examination and imaging modality.

The study group included 77 chronic stroke patients

(46 males and 31 females) , mean age (60.2 ± 9.8) ,
mean BMI (26.20 ± 4.3) matched with 154 healthy
control group (individuals without disorders of the ankle
or had no surgical intervention of the lower limbs) (90
males and 64 females) , mean age (59.9 ± 9.6) mean
BMI (26.7
± 3.78).
Figure 1: A musculoskeletal ultrasound image of
Inclusion Criteria: The events of stroke (hemorrhagic
the anterior talofibular ligament and thickness
or ischemic stroke) at least 6 months, who have measurement (49)
developed weakness on one side with abnormal gait.
Results (BMI) was 26.20 ± 4.3 in stroke cases and 26.7 ± 3.78 in
controls with no significant difference, (P > 0.05).
A total of 77 chronic stroke cases and 154 controls
were enrolled in this study, both groups were almost History of diabetes mellitus was relatively more
matched for age and gender, where the mean age was frequent in stroke cases, contributed for 32.5% while
it was reported in 23.4% of controls, however, the
60.2
difference was statistically insignificant, (P> 0.05) .
± 9.8 in patients and 59.9 ± 9.6 in controls, (P > 0.05). Hypertension was also more frequent in stroke cases
Males were almost dominant in both groups represented than controls, 54.5% and 43.5%, respectively with no
59.7% and (58.4%) among stroke cases and controls, statistically significant difference (P > 0.05) (table 1).
respectively, (P > 0.05) . The mean body mass
index

Table 1: Demographic characteristics of the studied group

Group
Variable Statistic Stroke cases Controls P Value
(N = 77) (N = 154)
Age (years) Mean ± SD* 60.2 ± 9.8 59.9 ± 9.6
0.85
Range (years) 83 - 37 82 - 37
BMI (Kg \ m2) Mean ± SD* 26.20 ± 4.3 26.7 ± 3.78
0.43
Range (Kg \m2) 32 - 20 33 - 20
Sex Male n (%) 46 (59.7) 90 (58.4)
0.82
Female n (%) 31 (40.3) 64 (41.6)
History of diabetes Mellitus n (%) 25 (32.5) 36 (23.4) 0.14
History of Hypertension n (%) 42 (54.5) 67 (43.5) 0.11

Among the stroke cases, right side was affected in 43 (55.8%) cases and the left side in the remaining 34 cases
(44.2%). Tthe disease duration of stroke cases ranged (6 – 36) months with a mean of 18.8 ± 10 months.

The comparison of mean ATFL thickness of stroke cases and controls revealed that ATFL was significantly
thicker in stroke cases than controls; the mean ATFL thickness was significantly higher in both affected and
unaffected sides in stroke cases than controls, 2.74 ± 0.25, 2.52 ± 0.27 and 2.34 ± 0.22 mm respectively,
Furthermore, within the stroke cases the mean ATFL thickness was significantly higher in the affected than
unaffected side, (P. value <
0.001). (tables 2) and (figure 3.2).

Table 2: Results of ANOVA multiple LSD (least significant difference) comparison of ATFL thickness
of stroke cases and controls
Mean Standard 95% Confidence Interval
Comparison P. Value
difference error of the difference
Affected vs. unaffected side 0.219 0.039 0.142 – 0.296 < 0.001
Affected side vs. controls 0.398 0.031 0.331 – 0.465 < 0.001
Unaffected side vs. control 0.179 0.033 0.112 – 0.246 < 0.001
Figure 2: Graphical comparison of mean ATFL thickness of stroke cases and controls

To assess the possible effect of demographic variables in both stroke cases and controls on the ATFL thickness,
inter-correlation was performed for these variables against the ATFL thickness in affected and unaffected side (table
3), the results of these correlations revealed that the ATFL thickness not affected by the demographic characteristics
of the stroke cases, in all comparison, (P>0.05).

Table 3: Correlation matrix of the ATFL thickness with demographic characteristics of stroke cases (N = 77)
Variable Statistic ATFL thickness affected side(cm) ATFL thickness unaffected side
R 0.05 0.08
Age
P. value 0.65 0.52
R 0.01 -0.05
Sex
P. value 0.96 0.68
R 0.19 -0.12
BMI
P. value 0.11 0.30
R -0.17 -0.09
Diabetes Mellitus
P. value 0.14 0.43
R 0.08 -0.13
Hypertension
P. value 0.49 0.25
R 0.07 0.12
Disease duration
P. value 0.56 0.31
Similarly, the inter - correlation was performed in control group, (table 4), and the results of these correlations
were also statistically insignificant, (P > 0.05).
Table 4: Correlation matrix of the ATFL thickness Furthermore, dynamic sonography (during
with demographic characteristics of controls (N = externally applied stress) has the potential to identify
154) ligament (11).
ATFL ATFL In the present study, it has been shown that the
thickness thickness mean thickness of ATFL in stroke cases was
Variable Statistic
affected unaffected
significantly higher than the mean thickness of ATFL in
side(cm) side
control group and the mean ATFL thickness was
R 0.044 0.044 significantly higher in both affected and unaffected
Age
P. value 0.58 0.57 sides in stroke cases than the mean thickness in control
R 0.11 0.13 group. In addition, in the stroke cases the mean ATFL
Sex
P. value 0.17 0.17 thickness was significantly higher in the affected than
R 0.041 0.41 the unaffected side, while in control group there was no
BMI significant difference of the mean ATFL thickness
P. value 0.62 0.62
R 0.026 0.031 between both sides.
Diabetes
Mellitus P. value 0.75 0.71 Yildizgoren, M. et al (14). studied (38) patients
R 0.049 0.047 with chronic stroke and (38) normal control group and
Hypertension
P. value 0.55 0.57 to the best of our knowledge this is the only available
research that investaged ATFL thickness in patients with
Discussion post stroke hemiparesis. He found that chronic stroke
patients have a thicker ATFL on both the affected and
Stroke is one of the commonest diseases affecting unaffected sides, compared with healthy individuals
people world - wide, chronic stroke patients with (2.75 ± 0.41, 2.42 ± 0.30, 2.35 ± 0.19 mm) respectively.
weakness on one side have higher risk of fall and ankle This is consistent with our study which showed that the
ligament injury, equino varus deformity is the result of mean ATFL thickness was significantly thicker in both
abnormal activity in multiple muscles, it occur in affected and unaffected side in stroke cases than mean
20 thickness in control groups (2.74 ± 0.25, 2.52 ± 0.27 and
% of patients with stroke. Although most studies have 2.34 ± 0.22 mm) respectively.
focus on gait patterns of stroke patients, the presence of
an equino varus foot was not specified, It can be postulated that these findings may be due
subcategorization of gait patterns would be helpful to several factors. Hemiplegic patients often have
in developing and delivering more targeted treatment. inadequate ankle dorsiflexion due to loss of motor
control, spasticity of the gastrocnemius soleus or the
Ultrasound is now widely used for the assessment invertor group, and/ or ankle contracture(14). Because a
of the tendon and ligaments abnormalities, healthy ligament is a highly organized fibrous tissue, its
ligaments contain high level of collagen with a structural mechanical properties are directionally dependent on
orientation. Changes to ligaments as a result of disease stress, an increased thickness of the ATFL reflects
and injury can give rise to a spectrum of damage, the morphologic changes that occurred secondary to the
mildest form is interstitial tearing of collagen fibers in ankle injury(14).
which the ligament may be elongated and lax.
Ultrasound is one of the most sensitive tools to The viscoelastic characteristic of ligaments is the
diagnoses the injury of ligaments and other soft tissues gradual increase in ligament deformation over time
and quantify the ligament integrity .(11) under a constant load. Recruitment of collagen fibers
may be important for resisting gradual deformation
Ultrasound could be used to evaluate thickness and of the ATFL under a constant load, and the ATFL is
type of the injury of the ATFL(12). It has been shown thickened on the affected side (14).. The stabilization of
that ultrasound has high sensitivity and specificity for the ankle in a neutral position reduces the load on the
chronic ATFL tear, Advantages of using ATFL and prevents ankle torsion.
musculoskeletal ultrasound include cost - efficiency,
shorter examination time, and the ability for real - time The use of ultrasonography can aid in early
and dynamic imaging. It also utilizes no ionizing detection of the affected ligaments, thus helping to
radiation and is portable, as well as widely available(13). prevent ankle deformity.
In this study hypertension, diabetic mellitus and treatment of spastic equinovarus deformity of
disease duration had no significant effect on ATFL the
thickness. foot and ankle. Foot ankle Int. 2002;23(8):738–43.
7. Ward AB. A literature review of
Conclusion the
pathophysiology and onset of post‐stroke
ATFL is thicker on the affected side than the
spasticity. Eur J Neurol. 2012;19(1):21–7.
unaffected and both of them are more thick than in the
feet of control group. 8. Bakheit AMO. The pharmacological management
of post-stroke muscle spasticity. Drugs Aging.
Conflict of Interest: None 2012;29(12):941–7.

Source of Funding: None 8. Bakheit AMO. The pharmacological management

of post-stroke muscle spasticity. Drugs Aging.
Ethical Clearance: Informed consent was obtained 2012;29(12):941–7.
from all individuals participant included in the study.
9. Peurala SH, Karttunen AH, Sjögren T, Paltamaa
J, Heinonen A. Evidence for the effectiveness of
REFERENCES
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10. Mulroy SJ, Eberly VJ, Gronely JK, Weiss W,
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Munoz M, Salle JY, et al. Epidemiology of pes after stroke: impact of ankle plantar flexion
varus and/or equinus one year after a first cerebral contracture. Prosthet Orthot Int. 2010;34(3):277–
hemisphere stroke: apropos of a cohort of 86 92.
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11. Ahmed R, Nazarian LN. Overview of
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3. Da Silveira ACP. Extended biomechanical model 2010;26(1):27–35.
of the ankle-foot complex - incorporation of
12. Cai Y, Li S, Chen S, Hua Y, Shan J. Suppl-4,
muscle and ligaments - University of Coimbra,
M2: An Ultrasound Classification of Anterior
Ana Carolina Pinto da Silveria. thesis. 2015;99.
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anterior talofibular ligament injury. Acta
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6. Fuller DA, Keenan MAE, Esquenazi A, Whyte 14. Yıldızgören M, Velioglu O, Demetgul O,
J, Mayer NH, Fidler-Sheppard R. The impact of Turhanoglu A. Assessment of the Anterior
instrumented gait analysis on surgical planning: Talofibular Ligament Thickness in Patients with
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Med Ultrasound. 2017;25(3):145–9.
DOI Number: 10.5958/0976-5506.2019.01841.2

Classroom Control Patterns and its Relation to the five major

Factors of the Personality of Sports Education Teachers in
Babil Governorate

Aied Kareem Abdaun1, AbdulrhmanGhadhab AL-SAADI2, Haedar Sami Mohammed1

1
AL-Qasim Green University, Department of Sport, Babel, Iraq; 2AL-Nahrin
University, Department of Sport, Baghdad, Iraq

ABSTRACT
This study investigates the physical level of classroom control differed by the five major factors of
personality? Are there gender differences between the patterns of classroom control according to the five
major factors of the personality? Is there a relationship between the patterns of classroom control and the
five major factors of the personality of the physical education teachers? The objectives of the research are
to construct and codify the scale of the patterns of classroom control and to prepare and apply the scale of
the five major factors of the personality as well as the extraction of the standards and levels for the scale of
class control patterns.

Keywords: prepare, regulate, classroom control patterns, five major factors,

personality.
Introduction One of the models that described the personality is
the model of the five major factors of the personality,
The Introduction and Importance of Research: The
which contains five dimensions through which the
school is one of the most important institutions of the
Ministry of Education in which the student’s personality difference in personality is explained based on each
is formed, his ethics are refined, and knowledge which prevalent dimension among the teachers of physical
will be his weapon in the future is learned. It is the education, and it gives us a description of individual
cornerstone through which the student reaches his goals differences among teachers.
and it provides him with all means of success according
to the rules and regulations.(1,2) One of the most The importance of this research is to identify the
important components of the school environment is the patterns of classroom control practiced by teachers
classroom. Its management is both an important and of physical education, the five major factors of the
difficult task. It is an important part of the work of the prevalent personality, and the relationship between the
teachers of physical education (3, 4). The physical patterns of classroom control and the five major factors
education teacher is the main supervisor of the of the personality of the physical education teachers. (7)
classroom and is directly responsible for the
implementation of the educational process.(5) The Research objectives
1. To construct and codify the scale of the patterns
The classroom control is one of the bases upon
which to achieve the educational objectives of the of classroom control for physical education
educational process and its success, and its role is not teachers in Babil Governorate.
only to raise the level of academic achievement for 2. To prepare and apply the scale of the five
students, but also to contribute to their moral and social major factors of the personality for the physical
development, so the control is an educational process education teachers in Babil Governorate.
that requires control of behavior, passions and emotion
under the leadership in order to achieve a specific goal, 3. The extraction of the standards and levels for
it is considered a psychological and social needs the scale of class control patterns of physical
which the educational process seeks to develop it for education teachers in Babil Governorate.
students (6).
922 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 922

4. To identify the level of the classroom control and codifying standards which corresponds to the nature
patterns for physical education teachers in Babil of the current study.
Governorate.
The research Community and Sample: The research
5. To identify the relationship between the classroom community and its sample of physical education
control patterns and the five major factors of the teachers in Babil Governorate have been identified.
personality for physical education teachers in Their number was (759) of which (582) were male
Babil Governorate. teachers and (177) were female teachers. The size of the
6. To identify the gender differences between the research samples was (455) representing a percentage of
classroom control patterns for physical education (59.94). The sample of reconnaissance was (30)
teachers in Babil Governorate. teachers, construction sample was (190) teachers,
codifying sample was (190) teachers while the number
The Research Methodology and Field Procedure of the application sample was (200) teachers.

The Research Methodology: The researcher used the The research tools and used equipment: The current
descriptive approach in the method of survey studies. research tools include: 1- Sources and references 2-
The standard studies are suited to the process of building Questionnaire form 3- Laptop.(16)

Table 1: Shows the five major factor scale articles for personality according to dimensions
The Positive articles The negative articles
The dimension
The Articles Total The Articles Total
Neurosis 6,11,21,26,36,41,51,59 8 1,16,31,26 4
Extraversion 2,7,17,22,32,37,47,52 8 12,27,42,57 4
Openness to experience 13,28,43,53,58 4 23,33,38,48,3,8,18 7
Acceptability 4,19,34,49 4 9,14,24,29,39,44,54,59 8
Conscientiousness 60,50,40,35,25,20,10,5 8 15,30,45,55 4
33 27

The correction key was according to the 5-Likert scale, where the tester obtains the following answers
when
responding the articles of the scale as shown below:

Table 2: Shows the degree of response on the scale of the five major factors for personality
The Articles Strongly Agree Agree I have no opinion Disagree Strongly Disagree
The Positive 5 4 3 2 1
The negative 1 2 3 4 5
Determining the validity of the five major factor scale objectives, there must be a tool to measure the patterns
articles for personality: The researcher presented the of classroom control based on scientific bases and
(60) articles of the scale to (7) experts and specialists. appropriate to the Iraqi environment. After studying
The researcher used the test (Ka-2) to identify the valid the relevant researches and scales like studying (7, 8), the
and invalid articles. The results showed the validity of all researcher has taken the following steps:
articles where the calculated (Ka-2) value of (7) was
greater than the tabular value (3.84) with (0.05) Define the Objective and purpose of the scale: The
significance level and (1) degree of freedom. The experts aim is to construction and codify the scale of classroom
agreed to keep the answer alternatives as mentioned control patterns and its purpose is to identify the
above (8). prevalent classroom control pattern of the research
community represented by physical education teachers
Procedures for controlling the scale of the patterns in Babil Governorate.
of classroom control: For the purpose of achieving the
Steps of constructing the Scale: A good test should be of democratic pattern male teachers was (55) and female
prepared to include the whole curriculum in a balanced teachers was (27. The number of punitive pattern male
manner. The Steps of constructing the Scale are: teachers was (20) and female teachers was (3), whereas
the number of the authoritarian pattern male teachers
Determine the fields of scale: Seven dimensions were
was (22) and female teachers was (7). The number of the
presented to experts and specialists showing the validity
chaotic pattern male teachers was (53) and the number of
of the dimensions (patterns) of the democratic, chaotic,
female teachers was (13). On the scale of the five major
punitive and authoritarian. The dimensions (patterns) of
factors of the personality. There were (51) male teachers
(preventive, therapeutic, reprehensive) were excluded
on the neurosis factor and (5) female teachers. There
because the calculated (Ka-2) values are less than the
were (20) male teachers and (10) female teachers on the
tabular value (3.84) which was below the significance
extraversion factor and the openness to experience there
level (0.05) and degree of freedom (1).
were (21) male teachers and (7) female teachers. There
Presentation, analysis and discussion of results: The were (15) male teachers and (17) female teachers on the
five major factor scales and the classroom control conscientiousness factor, and there were (43) male
patterns have been applied to the application sample of teachers and (11) female teachers on the vigilant
(200) teachers representing a percentage of (26.35%). conscience factor. By this we have achieved the second
When the data were processed statistically, the number of research objective which is (the preparation and
male and female teachers who were categorized by the application of the scale of the five major factors of the
five major factors of the personality was determined. personality of the teachers of sports Education in Babil
The number Governorate).

Table 3: The Statistical description of the scale of the classroom control patterns according to the five
major factors of the personality

Standard
hypothetical
Total number

error
deviation
Standard
Number of

Minimum

Maximum

Arithmetic

Skaewness
median

median
articles

value

value
The

The patterns

Female Teachers
Democratic 27 13 48.00 37.00 59.00 47.41 6.53 0.26 0.45
Punitive 3 11 35.00 33.00 37.00 34.67 2.08 0.20 0.23
Authoritarian 7 10 34.00 31.00 37.00 35.43 2.44 0.92 0.79
chaotic 13 11 43.50 40.00 47.00 43.77 2.13 0.59 0.62
Total 50 45 192.50 166.00 219.00 185.12 9.19 0.73 0.87
Male Teachers
Democratic 55 13 35.50 23.00 48.00 40.29 4.95 0.67 0.32
Punitive 20 11 44.50 34.00 55.00 42.35 5.72 0.28 0.51
Authoritarian 22 10 45.00 40.00 50.00 44.36 2.90 0.62 0.49
chaotic 53 11 38.50 30.00 47.00 38.08 4.50 0.62 0.33
Total 150 45 152.00 138.00 166.00 152.17 8.14 0.66 0.08
The Total Scale
Democratic 82 13 41.00 23.00 59.00 42.63 6.43 0.71 0.27
Punitive 23 11 44.00 33.00 55.00 41.34 5.97 0.25 0.48
Authoritarian 29 10 40.50 31.00 50.00 42.20 4.77 0.89 0.43
chaotic 66 11 43.50 30.00 47.00 39.20 4.72 0.58 0.30
Total 200 45 178.50 138.00 219.00 160.41 11.43 1.23 0.79
It appears that the arithmetic median hypothesis of Normative Levels of the Classroom control Patterns
the scale of the classroom control patterns which were Scale: Three normative levels were determined. both
extracted from the achieved degree and its value (178.50) levels are good and weak (15.73%) The average level
is the largest achieved arithmetic median which was reached a rate of (68.27%) Of the area under the normal
(160.41). The arithmetic median achieved for the teachers distribution curve, where it appeared to us that the level
(152.17) is greater than the hypothetical median of of teachers is average but the misses and the sample as
(152.00) and is not Influential. We also see that the a whole were weak, representing (38.67%) For teachers
arithmetic median of female teachers is equal to (185.12) and (54%) For misses and (73%) For the sample as a
and is smaller than the hypothetical median which was whole of the research community as shown in the below:
(192.50).

Table 4: Shows the standard levels and percentage of the test of the classroom control patterns

The scale of the classroom Sample Weak 15.73% Average 68.27% Good 15.73%
control patterns number Number % Number % Number %
Categories 166 -183 184 – 201 202 – 219
Females
50 27 54 15 30 8 16
Categories 138-147 148-157 158-176
Males
150 45 30 58 38.67 47 31.33
Categories 138-165 166-193 194-221
The sample as a whole
200 146 73 42 21 12 6

The relationship between the classroom control patterns and the five major factors of personality:
The
researcher used the simple correlation coefficient (Pearson) and the results were as follows:

Table 5: Shows the correlational relationships between the classroom control patterns and the five
major factors of personality
The classroom control patterns
The Democratic The punitive The authoritarian The chaotic
Personal factors
Neurosis 0.06 0.63 0.51 0.11
Extraversion 0.45 0.09 0.12 0.13
Openness to experience 0.10 0.13 0.08 0.05
Acceptability 0.57 0.10 0.11 0.14
Conscientiousness 0.12 0.54 0.49 0.07
As shown above, it is found that the relationship sample as a whole was (weak) at (73%). As for the
between the Neurosis, the punitive and authoritarian female teachers, the level is also weak at (54%) The male
pattern is statistically significant as well as the teachers were at an average level of (38.67) and this is
extraversion with the democratic pattern is statistically a good indicator of their classroom control, especially as
significant, the acceptability was a statistical significant we know that this result may be due to the environment
with the democratic pattern while the conscientiousness that provides male teachers with a degree of control over
was a statistical significant with the punitive and the students and that their abilities are suitable for the
authoritarian pattern because the value of Sig was less work of controlling the classroom. As for the differences
than significant level (0.05). between male and female teachers, the significant for
female teachers in the democratic and chaotic pattern was
Discussion of Results higher and the reason for this result that female teachers
are mothers before everything, they are dealing with
After the standard levels of the scale have been their emotions and they are not cruel with the students
extracted, the level of classroom control for the research regardless of their gender, As for male teachers, they
have
the advantage in the punitive and authoritarian pattern, Ethical Clearance: Not required
as mister is hard on students when they violate the rules
and regulations. As for the differences in the fields of
classroom control patterns, it was found that differences
are random except the preference of the democratic
pattern on chaotic, and authoritarian on chaotic also,
The democratic pattern was the best pattern, as it was
represented by (82) teachers, followed by chaotic pattern
which was represented by (66) teachers.

Conclusion

By presenting, analyzing and discussing the results,

the researcher reached the following conclusions:
1. The scale of the classroom control patterns
has
been codified for physical education teachers.
2. The common personality factors were revealed,
the neurosis and the Conscientiousness factors
were common for male teachers, and the
acceptability and Conscientiousness factors were
common for female teachers.
3. The patterns of classroom control were revealed
and the dominant patterns for male teachers were
democratic and chaotic, and for female teachers
were punitive and authoritarian.
4. Three levels were extracted on the scale of
the
classroom control (good, average and weak)
5. The female teachers’ level was weak, and the
female teachers were average, and the sample as a
whole was weak.

The Recommendations: In light of the researcher’s

conclusions, he recommends the following:
1. Teachers need to learn about ways to distance
them
away from authoritarian and punitive patterns.
2. The need to prepare courses to help teachers of
physical education on how to practice classroom
control patterns.
3. The need for teachers of physical education to
know the modern patterns of classroom control and
its impact on the process of learning in the
classroom.

Conflict of Interest: Nil

Source of Funding: Self

REFERENCES
1. Ahmed Ben Faya. The role of teacher’s
supervisors and principals in providing an
effective classroom climate in the classrooms of
the elementary school in Medina. Master’s degree
thesis. Saudi Arabia. Umm Al Qura University.
Faculty of Education.
2006
2. Halima Bu hamla, control patterns practice for
intermediate school students and their relationship
to the appearance of violent behavior. Master’s
degree thesis. Algeria. Al Haj Lakhdar University.
Faculty of Humanities, Social sciences and
Islamic sciences. 2015
3. Halima Attia Hassan. The level of the practice
of teachers of private public schools in the
capital Amman Governorate for the patterns of
classroom control and its relation to psychogenic
pain disorder from their point of view. Master’s
degree thesis. Middle East University. Faculty of
Educational Sciences. 2016
4. Khadija khalal and Hassiba Meziane. Methods of
Behavioral classroom control for New teachers.
Algeria. University of Gilani bonoamana. Faculty
of Humanities and Social Sciences. 2017
5. Reem Salmon. Classroom control and its
relationship to the location of control for misters
and misses of the elementary education stage in
the city of Tartous. Tartus University Journal for
Research and Scientific Studies. Volume 1.
Issue
1. 2017
6. Reem Salmon et al. Self-efficacy and its relation
to classroom control patterns for teacher students.
Tishreen University Journal for Research and
Scientific Studies. Vol. Issue 6. 2016
7. Rima Mohamed El Moudy. The role of classroom
in achieving self- control for learners. Master’s
degree thesis. Syria. Tishreen University. Faculty
of Education. 2015
8. Saed ragoh, Patterns of school control and
its relation to the effectiveness of classroom
control from the point of view of teachers.
Master’s degree thesis. Algeria. University of
8-Mohammed Khader. Faculty of Humanities and
Social Sciences. 2014
DOI Number: 10.5958/0976-5506.2019.01696.6

Effect of Speed Training Technique in Determining the

Effectiveness of Creatine and Phosphorus for Advanced
Volleyball Players

Amal Sabeeh Salman Al-Tamimi

University of Diyala, Faculty of Basic Education, Department of Physical Education and Sports Sciences

ABSTRACT
The importance of research is to maintain the production of energy and non-disbursement in a large way
and it is only through the right and appropriate training, including the method of increasing speed and thus
put the scientific information for trainers on the importance of maintaining the production of energy for
players through the implementation of this training and testing.
This study aimed to prepare the training of increasing speed in determining the effectiveness of creatine
and phosphorus for advanced volleyball players. Also, to Identify the impact of high intensity training in
determining the effectiveness of creatine and phosphorus for advanced volleyball players.
This study concluded that, the technique of speed training is especially important in the production of
energy after decomposition of creatine and phosphorus during the appropriate training. Also,
Experimenting with appropriate training and investigating the facts of speed and its importance in the
volleyball game in the production of energy through the control of creatine and phosphorus also, this study
recommendations that, adopting the method of training of increasing speed is especially important in the
production of energy after decomposition of creatine and phosphorus during appropriate training. Also, the
need to emphasize the experimentation of appropriate training and investigating the facts of speed and its
importance in the game of volleyball in the process of energy production through control creatine and
phosphorus.

Keywords: Speed training technique, creatine phosphorus volleyball players

Introduction maintain its speed and strength without falling during that
period, it must be training in a manner that can control
Human Health The most important thing that
the discharge necessary energy for performance. (3)
is sought in scientific research and how to raise the
functional variables to the best using either necessary Therefore, the method of increasing speed, which
nutritional supplements or exercise activities that work ranges from speed to slow to the maximum speed,
on functional changes that raise the health offenders of is sometimes more controlled by functional changes
the human. (1) physiological, including creatine and phosphorous
necessary in dealing with energy. (4)
When functional changes and energy production
are related to the exercise of any physical activity here, The power out of the (ATP) needs constant
we need to be precise in dealing with the methods of compensation of energy during sports activity through
training in a true scientific way as they control the creatine phosphate, which is one of the sources of energy
energy production necessary to complete the game and and stock in the cells of the body because of its impact
achieve good results in the game in practice.(2) on the phenomenon of extending the body and fills the
shortage of energy sources during physical performance.
The game of volleyball is characterized by speed (5)

in the implementation of basic skills both in defense or

attack and during periods of the game, which lasts more Hence, the importance of research is to preserve the
than two hours in some cases, which requires the player production of energy and non-drainage in a large way
to and it is only through the right and appropriate training,
927 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 927

including the method of increasing speed and thus we by identifying the effect of the technique of
put a scientific information for trainers on the increasing
importance of maintaining the production of energy for
players through the implementation of this training and
testing.(6)

Increasing Speed Training Method: It is a modern

sports training method that helps the athlete to increase
the speed of performance gradually from easy to
difficult and thus avoid sports injuries in addition to the
development of special speed of the game, this is what
(Amarullah Ahmed Al-Bassati, 1998)”1” confirm it.
((This method is the gradual increase of running speed
from (jogging to running) to the enemy at full speed and
then rest in walking and improves this type of training
both speed and strength). (7)

Blood creatin is an important indicator to measure

the amount of physical effort, as it changes after physical
exertion. Creatine changes to creatinine after loss of
water molecule. The normal values of creatine in the
blood for healthy people are about 0.5 - 0.9 mg/100 ml
serum)(8).

There is about 98% of muscle creatine in the form

of phosphocrytin (CP), which is a high energy source in
muscles) (9).

Phosphate has the ability to bind in reverse with

many enzymatic systems and other essential compounds
of metabolic processes and is related to the functions of
ATP, ADP and phosphocrytin, which produce energy.
(10).

2-Research Problem: The energy spent by the player

suits the specificity of the game and the training which
the player exercises to win and the good results. In the
absence of proper training with the system of energy
exchange will not raise the level of the player with the
effort and sure to drop the level and not to win.

And through the humble experience of the

researcher as a player and specialist in the science of
physiology found that experimentation is an important
factor in investigating the scientific facts of the quality
of the training and its physiological impact, so it is
necessary to know each method of training and its
specialties in upgrading the functional side and energy
production in the body of the player, including creatine
and phosphorus, Perhaps not studied in terms of
physiological and specificity of the game, including the
game of volleyball. (11)

Therefore, the researcher decided to study this

problem
928 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 928
speed in determining the effectiveness of creatine and
phosphorus for advanced volleyball players.(12)

Research Goals:
1. Prepare the training of increasing speed in
determining the effectiveness of creatine and
phosphorus for advanced volleyball players.
2. To identify the effect of high-intensity training
in determining the effectiveness of creatine and
phosphorus for advanced volleyball players.
3. To identify the differences between the results
of (pre/post) (Before/After) tests in determining
the effectiveness of creatine and phosphorus for
advanced volleyball players.
4. To identify the differences between the control
and experimental groups in determining the
effectiveness of creatine and phosphorus for
advanced volleyball players.

3-Research Hypotheses:
1. There are significant differences between the
results of (pre/post) (Before/After) tests and for
the benefit of post (After) test in determining
the effectiveness of creatine and phosphorus for
advanced volleyball players.
2. There are significant differences between the
control and experimental groups and for the
benefit of the experimental group in determining
the effectiveness of creatine and phosphorus for
advanced volleyball players.

Material and Method

Research Areas:

Human Field: Volleyball team players in the Faculty of

Basic Education/Diyala University.

Spatial Field: the Faculty of Basic Education/Diyala

University and Shams laboratory for pathological
analysis in Baquba Al-Jadida/Tabu Street.

Time Zone: Duration from 3/12/2018 to 13/2/2019.

Field Procedures:

Research Methodology: The researcher used the

experimental method with the sample of the controlled
and experimental groups to suit the solution of the
research problem and achieve its objectives.
Research Community and Its Sample: The research the tournaments. The sample was randomly divided into
community is identified in a deliberate manner for the two groups (controlled and experimental groups), so that
volleyball players of the applicants who represent the the number of each group was 6 players and the sample
volleyball team in the College of Basic Education/ formed 60% of the original society.
University of Diyala and their number are (20) players.
The sample was homogenized within the group by
After that, 12 players were selected from the using the difference coefficient and the equivalence of
main the two groups using the (t) test as in Table (1).
team, who continued the training and the participants in

Table 1: Demonstrates the homogeneity and equivalence of the control and experimental groups
The experimental group Controlled group
Level of Calculated Coefficient
Coefficient Measurement t
significance t-value of SD M SD M
of variation
variation
Not
0.013 2.013 3.61 179.25 2.042 3.66 179.22 Length/cm 1
significant
Not
0.378 2.915 2.5 85.74 2.1 1.79 85.22 Weight/kg 2
significant
Not
0.021 17.381 0.077 0.443 16.063 0.071 0.442 L/U Creatine 3
significant
Not L/U
0.14 3.598 0.113 3.14 3.555 0.112 3.15 4
significant phosphorus
The Schedule (t) value at the freedom level (10) and the level (0.05) = 1.812
Information Collection Methods Field Research Procedures:

Means of Data Collection: Determining Research Variables: Based on the

researcher’s humble experience and review of sources
1. Arabic references.
and references, the variables that the researcher
2. Exploration experience. considers necessary were identified as follows:
3. Measurements used. 1. Creatine.

Instruments and Tools Used: 2. The phosphorus.

1. Needle to draw blood samples. Exploration Experience: The researcher conducted

an exploratory experiment on 3/12/2018 on the same
2. Bottles to save blood samples.
research sample. The required exercises were applied for
3. Centrifuge the purpose of rationing the training load used according
to the method of increasing the speed and creating the
4. Cool Box to save blood samples with all
measurements required for measures, and the purpose of
requirements for obtaining ratios.
the experiment was to:
5. Optical analysis device
1. Knowing the required equipment and tools.
6. Electronic blood pressure device. 2. Knowing the right time.
7. six (6) Volleyballs. 3. Knowing the obstacles facing the researcher in the
8. Medical balance. future.

9. regulated volleyball playground. 4. The regulation of exercises and the calculation of

the appropriate size by the quality of training high
10. Metric tape measure. intensity and low intensity.
Measurements and method of procedure used: The Results and Discussion
researcher carried out the pre (before) measurement on
the members of the research sample after the By noticing and observing Table (2) and (3) we can
performance of a high intensity training unit and then see significant differences in controlled and experimental
the blood was withdrawn by 5 cm cubic by a specialist groups in pre/post measurements. This is an evidence
pre and post (before and after) the training curriculum of of improvement in the physiological variables under
the research sample and laboratory treatment for study, including creatine and phosphorus, which are
measuring creatine and phosphorus through laboratory important in conserving energy sources. This is due to
treatment. the training that is used and positively influenced by the
physical loads that saved the energy production through
Field Experience: correct analysis For the important compounds creatine
and phosphorus “to decompose the chemical bonds in
Pre (Before) measurement: The pre (before)
phosphocrytine resulting in the emission of energy that
measurement was conducted on 17/12/2018.
reproduces ATP. (15)
Main Experience and used Training: After learning
As the regularity of the sample in the training and
the conditions and components of load for the method
the use of additional loads of the set, this is consistent
of training, increasing speed, a set of exercises for the
with the statement by Karima Ahmed Fattouh, “The
technical performance of volleyball was developed
regularity in the training program lead to the creation of
and applied in this method, which is determined by the
some physiological variables of the body as a
intensity of the training and ranges (90-100%).
manifestation of adaptation to the nature of that activity.
The exercises were implemented in the main section (13)

of training units of the trainer during the special number

Table (4) shows differences between the controlled
period at a rate of (3) units per week and for two months
and experimental groups and for the benefit of the
(24) training units.
experimental group, in which the researcher considers
The size of the load was determined according to to be due to the increased training technique used as a
the intensity set. The rest was based on pulse return method of handling high stress intensity and affecting
(120-130 bpm) and time was calculated to rest during the process of energy production. As the responses and
the pulse. The application of the exercises was from changes that occurred during the application of this
18/12/2018 to 12/2/2019. training course, which led to the events of a state of
real-time and cumulative adjustment of the increase in
Post (after) Measurement: The post-measurement is
the amount of muscle compounds in the recovery, and
carried out on 13/2/2019.
this cycle increases the energy stocks within the muscles
Statistical Method working after the combination of compounds to form a
phosphocrytine compound (CP).Which is reflected in
Using (spss) system with statistical treatments the increase in the proportion of stocks of energy
and
sources to be an important factor in the events of speed
to find the following:
as it is the first key to the operation of energy systems
1. Arithmetic mean (M). after (ATP) because of the very low amount of energy
2. Standard deviation (SD). funding to the working muscles(14), which led to the body
to consume compound (CP) due to physical
3. The difference performance. The increased level of serum creatine
coefficient.
phosphate (CP) in the muscle changes particularly in
4. Test (t) for interrelated samples. sports activities that require high performance and short-
5. Test (t) for independent samples. term durability in order to ensure the reconstruction of
ATP (14).”
6. Percentage.
Table 2: Shows the pre/post (t) value of the controlled group

Level of Calculated (t) The standard Post (after) Pre (before)

Measurements
significance value error SD M SD M
significant 5.333 0.015 0.021 0.522 0.071 0.442 L/U Creatine
significant 2.272 0.044 0.023 3.25 0.112 3.15 L/U phosphorus
The Schedule (t) value at the freedom level (5) and the level (0.05) = 2.015

Table 3: Shows the pre/post (t) value of the experimental group

Level of Calculated (t) The standard Post (after) Pre (before)

Measurements
significance value error SD M SD M
significant 4.269 0.078 0.241 0.776 0.077 0.443 L/U Creatine
significant 3.66 0.112 0.146 3.55 0.113 3.14 L/U phosphorus
The Schedule (t) value at the freedom level (5) and the level (0.05) = 2.015

Table 4: Shows the post (t) value of the controlled and experimental groups

Level of Calculated Experimental group Controlled group

Measurements t
significance (t) value SD M SD M
Significant 2.351 0.241 0.776 0.021 0.522 L/U Creatine 1
Significant 4.545 0.146 3.55 0.023 3.25 L/U phosphorus 2
The Schedule (t) value at the freedom level (10) and the level (0.05) = 1.812
Conclusions and Recommendations 2. Majid Ali Mussa, The effect of the formation
of the speed-lengthening training loads in
Conclusions: Throughout the results, the researcher
some functional and 3.Rissan Khrebit Majid,
concluded the following:
Biochemical and physiological analysis in sports
1. The technique of growing (increasing) speed training: Dar Al-Hikma, University of
training is especially important in the production Basra,
of energy after decomposition of creatine and 1991, p 146.
phosphorus during the appropriate training. (12)
4. Gaiton and Hull, (Translated by Sadiq Al- Hilali).
2. Experimentation an appropriate training and Reference in medical physiology: World Health
investigating the facts of speed and its importance Organization, Regional Office for the Eastern
in volleyball in the process of energy production Mediterranean, 1997.
through the control of creatine and phosphorus.
5. Muhammed Nasraddin Radhwan, Methods of
Conflict of Interest: Nil measuring physical effort in sport, Book center,
Egypt: 1988.
Source of Funding: Self
6. Karima Ahmed Fattouh, Physical fitness
Ethical Clearance: Not required relationship with some physiological
characteristics of swimming practices in Kuwait;
REFERENCES Journal of Studies and Research, Faculty of
Education for Sports, Helwan University;1992.
1. Amarullah Ahmed Al-Bassati, Principles and
rules of sports training and its applications: 7. Muhammed Hassan Alawi and Abw Alaa Ahmed
Alexandria, the establishment of knowledge, Abdul Fatah, Physiology of Sports Training: Arab
1998. Thought House, Cairo, 2000.
8. Amarullah Ahmed Al-Bassati, Principles and Organization, Regional Office for the Eastern
rules of sports training and its applications: Mediterranean, 1997, p 1076.
Alexandria, the establishment of knowledge,1998,
12. Muhammed Nasraddin Radhwan, Methods of
p 98.
measuring physical effort in sport, Book center,
9. Majid Ali Mussa, The effect of the formation Egypt: 1988, p48.
of the speed-lengthening training loads in some
13. Karima Ahmed Fattouh, Physical fitness
functional and biochemical variables in short
relationship with some physiological
run distances: PhD thesis, Faculty of Physical
characteristics of swimming practices in Kuwait;
Education, University of Basra,2003, p38.
Journal of Studies and Research, Faculty of
10. Rissan Khrebit Majid, Biochemical and Education for Sports, Helwan University;1992.
physiological analysis in sports training: Dar Al-
14. Muhammed Hassan Alawi and Abw Alaa Ahmed
Hikma, University of Basra, 1991, p 146.
Abdul Fatah, Physiology of Sports Training: Arab
11. Gaiton and Hull, (Translated by Sadiq Al- Hilali). Thought House, Cairo, 2000, p352.
Reference in medical physiology: World
Health
DOI Number: 10.5958/0976-5506.2019.01697.8

Study of the Effect of Different Intensity and Duration of LED

Light on Shear Bond Strength and Adhesive Remnant Index of
Metal Orthodontic Brackets

Zahraa M. Al-Fadhily1, Sattar J. Abdul-Zahra Al Hmedat2, Zuha Ayad Jaber2

1
B.D.S., M.Sc. Orthodontic Lecturer, P.O.P. Department, 2B.D.S., M.Sc., Department of
Conservative
Dentistry, College of Dentistry, University of Kufa, lraq

ABSTRACT
Background: Bonding of orthodontic brackets of fixed orthodontic appliance by using acid etch technique
was first introduced in 1955. LED-based light sources posses many benefits as minimal heat generation.
There is a new generation of LED light cure corporate with three different intensities (standard, high
power and extra power). Objective: this study was aimed to evaluate the effect of increasing intensity and
decreasing duration of LED light on shear bond strength and adhesive remnant index of metal orthodontic
brackets.
Materials and Method: Sixty healthy extracted maxillary premolars were divided into three groups of
twenty teeth for each, group (Ι) cure with a standard LED light curing (1000mW/cm2) for 10 seconds,
group (ΙΙ) cured through a high-intensity LED curing light (1400mW/cm2) for 8 seconds, group (ΙΙΙ)
cured with a extra high-intensity LED curing light (3200mW/cm2) for 6 seconds. The teeth mounted in
acrylic resin, Shear bond strength test was done. Then, adhesive remnant index (ARI) was evaluated. Data
were analyzed by one-way analysis of variance ANOVA test and LSD, and Fisher exact test.
Results: The results showed that there were statistically significant differences among the study groups. The
maximum value of shear bond strength was for group ΙΙΙ (17.834 ± 0.367) and the minimum shear bond
strength value was for group Ι (8.888 ± 0.307). ARI scores showed a statistically significant differences
among groups, with a high tendency toward score 1 and score 0 in all three groups.
Conclusion: High intensity LED light with low curing duration has advantage of increasing bond strength
in addition to reducing chair time taken for curing procedure and enamel cleaning following de-bonding
procedure without any effect on the enamel integrity.

Keywords: LED lights, shear bond strength, ARI, orthodontic brackets, maxillary premolars, chair
time.

Introduction diodes (LED) technology [6]. These devices vary in

their energy source, light intensity and wavelength [7,8].
Bonding of orthodontic brackets of fixed
With TQH technology just 1% of the over-all energy
orthodontic appliance by using acid etch technique was
input is used for light emission and generated as heat
first introduced in 1955 [1], as just auto-polymerizing
with residual energy [9]. The Halogen bulbs units supply
materials were obtainable at that time [2]. With
400-900 mW/cm2, and need 40-second light curing per
introduction of light- cured adhesives, these materials
situate to become sufficient polymerization of adhesives
became widely accepted among orthodontists since they [10]
. Argon laser or plasma arc light curing devices are
provide ample working time to accurately locate the
costly, complicated and of relatively large size [11].
orthodontic bracket on the enamel surface, to clean any
overflow material, ease of use and allow immediate The use of light curing LED units of gallium
insertion of archwire [3]. In the last several years, various nitride blue light-emitting diodes in orthodontics was
light-cured devices have been introduced including firstly suggested by Mills [12].Following that time,
Tungsten-quartz halogen curing units (TQH) [2,4], more efficient LED devices had developed in order
Halogen light-curing units [5], argon laser, xenon to increase performance of photo-activation
plasma arc and solid-state light-emitting and
933 Indian Journal of Public Health Research
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 933

reduce polymerization time, so this will decrease chair hypoplastic areas (teeth were examined by using light
time, offering more comfort to patient and fulfilling curing unit).
professional requirements [2, 7,13]. LED-based light
sources posses many benefits as minimal heat
generation, this reduced temperature because LEDs have
a lifecycle over 10,000 hours ineffective of significant
degradation in light output [14], small size, ergonomic,
less weight, low power consumption, reduced noise
generation, longer life source of radiation, light emission
spectrum with most dental photo-initiator techniques
using camphoroquinone as the di-ketone absorber, with
the greatest absorption in the blue section of the visible
light spectrum at a wavelength of 470nm [2,5,7,13,15]. Also,
the LED lights are resistant to shock and vibration and
do not need filters to produce blue light [2,16]. LED lights
can succeed optimum result of clinical bonding with
inferior curing time when compared with the
conventional curing system [17-19]. For all these positive
characteristics, the technology of light-emitting diode is
presently the most popular method of light curing for
orthodontic bracket bonding [2,15,20,21].

It is imperative to remember that high strength of

bond values are inherently critical, as they can cause
enamel breakages during removing of the brackets
[22,

. The ARI index gives an idea about the effect

23,24]

of
shear bond strength on the tooth.

There is a new generation of LED light cure

corporate with three different intensities (standard, high
power and extra power). The purpose of this study was
to evaluate the effect of three different light intensities
with different time exposure in vitro on shear bond
strength and ARI of metal orthodontic brackets as to
whether they allow more curing time reduction without
reducing shear bond strength or they do not. In
addition, study their effects on the ARI.

Materials and Method

Teeth Samples: Sixty extracted human maxillary first

premolars were gathered from two orthodontic clinics.
The teeth were cleaned off debris and saved in normal
saline solution in a closed container at room temperature
(22°C
± 3) and normal saline replaced continuously to
avoid
bacterial growth until the time of bonding procedure.

The inclusion criteria of samples included: no

caries, no cracks, no visible decalcification and or
934 Indian Journal of Public Health Research
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Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 934
Before bonding procedure, all buccal surfaces of surface (Sealant resin, Resilience light cure adhesive;
the teeth were cleaned and then polishing with non- Ortho-Technology; Fl/USA). Maxillary first premolar
fluoridated pumice for 20 seconds. Teeth were irrigated stainless steel brackets were bonded to the teeth usage
with water spray for 10 seconds and then dried with adhesive paste (Resilience light cure adhesive; Ortho-
triple air syringe for 10 seconds before mounting Technology; Fl/USA), positioned the bracket on the
procedure. Thereafter, the teeth distributed randomly buccal surfaces of the tooth in the desired position with
into three groups of 20 teeth in every group. minimum force and following placement pushed firmly
in order to be positioned accurately. After that, clean
Mounting Procedure: The investigator used large excess of adhesive paste flow out from under the bracket
fissure bur to do a retentive groove in the teeth to with a sharp scalar. Resin was cured by using Valo
enhance the teeth keeping within the acrylic blocks Ortho LED curing light (Ultradent, South Jordan, UT)
serrated all teeth. Then, the teeth were vertically (Figure 1) at the same light-tip distance (10mm) with the
mounted in a block made from self-cure acrylic; hence, following procedures:
the crown was uncovered and the buccal view was
directed to be parallel to the surveyor analyzing rod. Group Ι: 20 teeth were cured with a standard LED
Thus, the applied force would be at 90 angle to the
0
curing light (1000mW/cm2) for 10 seconds, 5 seconds
bracket-tooth interface [22]. from medial surface then 5 seconds from distal surfaces.

Etching and Bonding: The whole buccal surfaces of Group ΙΙ: 20 teeth were cured by a high-intensity LED
all teeth were etched with the 37% phosphoric acid gel curing light (1400mW/cm2) for 8 seconds, 4 seconds
(Etching agent, Resilience; Ortho-Technology; Fl/USA) from medial surface then 4 seconds from distal surface.
for 20 seconds. Later, teeth were washed with copious
water and dried for approximately 20 seconds until the Group ΙΙΙ: 20 teeth were cured with a extra high-
enamel appeared chalky white. Subsequently, a primer intensity LED curing light (3200mW/cm2) for 6
was applied with a cotton applicator on etched buccal seconds, 3 seconds from medial surface then 3 seconds
from distal surface.
(N). The readings were gained in kgf (Kilogram-force),
Light intensities of VALO device was examined changed into N (Newton), then the shear bond strength
by using a radiometer (Demetron, Kerr Corporation, was determined by dividing the force by bracket surface
Orange, Calif) to confirm the manufacturer light area, with average surface area of the bracket base was
intensities values before starting the study. (12.4mm2), so the shear bond strength measured values
in MPa.

Adhesive Remnant Index Assessment: Following

the debonding procedure, the debonded enamel area
of teeth and the brackets were checked by using a
Figure 1: Valo Ortho LED curing light stereomicroscope with magnification of X20 (Olympus,
Tokyo, Japan) in order to evaluate the ARI and at the
Shear Bond Strength Test: Using a testing universal same time carefully examine the integrity of enamel
machine (model 4411; Instron, Norwood, MA, USA), surface. Depending on ARI scores as determined by
at cross-head velocity about (0.5mm/min) via testing Artun and Bergland [25].
machine (Figure 2). Score 0 = the enamel free from any adhesive
remaining.
Specimens positioned in acrylic resin were prepared
Score 1 = the enamel contain less than half of
in a way that the brackets were perpendicular to the
adhesive.
shear blade. All study groups were submitted to the
Score 2 = the enamel contain more than half of
shear bond strength test with placing the tip of active
adhesive.
shear blade on the superior portion of the bracket base
Score 3 = whole the enamel covered with the
(Figure 3), and the force was directed to the bracket‒
adhesive remaining.
tooth interface by a blade at a cross-head velocity of
0.5mm/minute till the bracket detached.

The maximum force applied for de-bonding the

bracket from tooth surface was recorded in Newton
935 Indian Journal of Public Health Research
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of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 935

Figure 2: Instron machine

Figure 3: Shear bond test

Statistical Analyses: Statistical analyses were

performed using ANOVA test and LSD test to figure out
any statistical difference in shear bond strength values of
the three light intensities. The difference in ARI scores
between the three groups was examined by Fisher exact
test. The significance levels depended on statistical
analysis as follows: (0.05≥P>0.01) considerably
significant, (0.05 ≥ P>0.001) highly significant and
(P>0.05) non-significant.

Results

Descriptive statistics for measured shear bond

values of three groups were demonstrated in Table (1).
The mean shear bond strength (measured in MPa),
standard deviation (SD) and statistical comparisons for
three groups were showed in Table (2).
The statistical analysis of the results using One-way LSD test showed that there were statistically significant
analysis of variation (ANOVA) was related to determine differences among the groups (Table 2).
any significant differences for values among groups.
The comparison of ARI scores of the three light
The ANOVA test showed that there were statistically
intensities showed statistically significant differences,
significant differences among the three groups. The with a high tendency toward score 1 and score 0 in all
highest mean ± SD shear bond strength value was for three groups (Table 3). Examination of enamel surface
group ΙΙΙ (17.834 ± 0.367) MPa; whereas the lowest of each tooth showed normal enamel surface without
value was for group Ι (8.888 ± 0.307) MPa. Also detachments or cracks.
the

Table 1: Descriptive statistics of shear bond strength values (MPa) for the three studied groups
Groups Mean SD Minimum Maximum
Group I 8.888 0.307 8.412 9.427
Group II 14.277 0.441 13.810 14.872
Group III 17.834 0.367 17.087 18.310

Table 2: Comparison of the shear bond strength values (MPa) among the three studied groups
Groups Mean (MPa) ± SD 95% CL P value LSD*
Group I 8.888 ± 0.307 8.668-9.108
Group II 14.277 ± 0.441 13.961-14.593 P≤0.001 2.763
Group III 17.834 ± 0.367 17.572-18.097
*LSD= 2.763 (Any difference in means of any two groups greater than 2.763 is considered significant)

Table 3: Comparison of ARI scores among the three studied groups

Groups Score 0 Score 1 Score2 Score3
Group1 7(35%) 8(40%) 4(20%) 1(5%)
Group2 7(35%) 9(45%) 3(15%) 1(5%)
Group3 8(40%) 9(45%) 3(15%) 0(0%)
Group 1 viz Group 2: Fisher Exact Test = 2.715, df=1 P-value =0.007**
Group 1 viz Group 3: Fisher Exact Test = 7.077, df=1 P-value =0.000**
Group 2 viz Group 3: Fisher Exact Test = 2.264, df=1 P-value =0.024*
** Highly significant. * Significant.

Discussion With provision of LED lights in the markets, the

manufacturers are continuously developing new LED
Orthodontic patients request for premium
devices with increased light intensity to reduce curing
orthodontic with brackets, but orthodontists are still
time, which subsequently reduces clinical chair time[26, 27].
concerned about their bond strength. So the study
tried to get better and easier ways to bond the brackets These improvements have moved to create the
used in fixed orthodontic appliances. Different recent superior bonding strength, at the same time must
advancements have been made to develop shear maintain enamel surface during treatment and after de-
bond strength, these advancements have focused on bonding.
getting better bond strength, shortening bonding time, There is a new generation of VALO-LED light
minimizing bonding steps number, and reducing the (Ultradent Products Inc.) with three different light
remnants of adhesive after debonding without effect on intensities mode and suggesting curing times for both
enamel surface of the teeth. metal and ceramic brackets (Table 3).
Table 3: VALO-LED light modes and suggesting curing times
Variables Standard High power Extra power
Power (Mw/cm ) 2
1000 1400 3200
Time (sec.) 1×10 2×4 2×3
Bracket debonding during treatment course can Ethical Clearance: Obtained from the Research Ethics
occur due to low shear bond strength [28], which will Committee at College of Dentistry/ University of Kufa,
delay treatment and cause discomfort to the patient. lraq.
Reynolds suggested that the lowest shear bond strength
level would be about (5.6-7.8) MPa nearly for all Source of Funding: Self-funded.
different orthodontic tooth movements [29]. According to
Reynolds lowest level, the three studied groups above Conflict of Interest: Nil.
the minimum shear bond level.
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DOI Number: 10.5958/0976-5506.2019.01698.X

Comparative Study between Muscle-Split Versus the Classical

Muscle-Cut Subcostal Incision for Open Cholecystectomy

Awni Ismail Sultan1, Khalid Khairi Hussein1

1
Department of Surgery, College of Medicine, Tikrit University, Salah Al-Deen, Iraq

ABSTRACT
Introduction: Many incisions have been advocated and used for open cholecystectomy. The right
subcostal incision is commonly chosen, in which abdominal wall muscles divided in the line of incision.
The aim of this study is to unreveal whether muscle splitting incision for open cholecystectomy affects
operative duration and blood loss, postoperative pain, duration of hospitalisation, then subsequent local
complications namely, wound infection and incisional hernia compared with the traditional rectus muscle
dividing open cholecystectomy.
Methodology: Analytic study included adult cases (n=120) that were undergone a right-sided subcostal
incisions for open cholecystectomy, who were not candidates for laparoscopic approach or those were
converted to open version. They were randomly divided into two groups (n=60 each) depend on the
operation type viz. classical muscle-cut subcostal incision (MCSI) group and same length, muscle-split
subcostal incision (MSSI) group. Patients were examined for operative time (calculated from starting
incision till closure of skin), intraoperative blood loss, postoperative pain (using the visual analogue score),
and length of hospitalization. Six weeks postoperatively, all incisions were followed, and any case of
surgical site infection or incisional hernia was reported.
Results: Regarding operative variables, the operative time is more in group MSSI (92.7min) with less
blood loss (12.3ml) than that in group MCSI (86.4 min) with more blood loss (28.6ml). The postoperative
pain is significantly less in group MSSI as compared to MCSI depending on visual analogue score, as the
following: day 1 (3.44 Vs. 1.56), day 2 (1.78 Vs. 0.90), and day 3(1.18 Vs. 0.76). Six weeks postoperative
follow up showed that 11 patients as 7(11.6%) in group MCSI, and 4(6.6%) of group MSSI) developed
surgical site infection; all were treated as outpatient cases. Besides, 4 patients as 3 patients (5%) in group
MCSI, and only
1case (1.6%) of group MSSI developed incisional hernia requiring surgical repair.
Conclusion: Muscle split subcostal incision is quite suitable for uncomplicated open cholecystectomy with
less operative blood loss, less postoperative pain, earlier discharge, and less postoperative complications,
namely wound infection and incisional hernia.

Keywords: laparoscopic cholecystectomy, Muscle split subcostal incision, Muscle-cut subcostal incision,
Postoperative complications

Introduction
The laparoscopic cholecystectomy is now
considered as the “gold standard” technique for the
management of gallstone disease 1. However, open
Corresponding Author: cholecystectomy still widely performed especially for
Khalid Khairi Hussein cases not appropriate for laparoscopy2, those converted
Professor in The College of Medicine, to open approach, or wherever facilities for laparoscopy
Tikrit University, Tikrit, Iraq are unavailable especially in developing countries 3,4.
Phone: 07722958462 Many incisions have been advocated and used for open
Email: [email protected] cholecystectomy, and the right subcostal incision is
939 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 939

commonly chosen5,6. It is the muscle division, which is The aim of this study is to reveal whether muscle
supposed to be responsible for postoperative pain and splitting incision (MSSI) for open cholecystectomy
the resultant local and systemic effects7. affects operative duration and blood loss, postoperative
pain, duration of hospitalisation, then subsequent local
Theodore Kocher8 originally described the subcostal complications viz. wound infection and incisional hernia
incision; it affords excellent exposure to the gall bladder compared with the traditional rectus muscle dividing
and biliary tract and can be made on the left side to open cholecystectomy.
afford access to the spleen8. It is of particular value in
obese and muscular patients and has considerable merit Materials and Method
if diagnosis is known and surgery planned in advance9.
The subcostal incision is started at the midline, about 2-5 Patient’s Enrollment: This study has been conducted
cm below the xiphoid and extends downwards, outwards at the Kirkuk General Hospital, for the period from
and parallel to and about 2.5cm below the costal December 2016 to August 2018. The patients (n=120)
margin7. Extension across the midline and down the with ages ranging between 20-60 years, who were
either contraindicated for laparoscopy, or those were
other costal margin may be used to provide generous
converted from laparoscopic to open procedure. Their
exposure of the upper abdominal viscera. The rectus
written informed consent was taken before operation.
sheath is incised in the same direction as the skin Classical muscle-cut subcostal incision (MCSI) group
incision, and the rectus muscle is divided with was included 42 females and 18 males. While, the
cautery; the internal oblique and transversus same length muscle-split subcostal incision (MSSI)
abdominis muscles are divided with cautery7,10. Special group includes 39 females and 21 males. All patients
attention is needed for control of the branches of the with features of acute cholecystitis or jaundice, diabetic
superior epigastric vessels, which lie posterior to and patients and those on chronic steroid use were excluded
under the lateral portion of the rectus muscle. The small from the study.
eighth thoracic nerve will almost invariably be divided;
All patients were investigated for confirmation
the large ninth nerve must be seen and preserved to
of diagnosis and anesthetic fitness. Patients were
prevent weakening of the abdominal musculature. The randomized in two groups, muscle splitting (MSSI)
incision is deepened to open the peritoneum7,11. and muscle dividing (MCSI) groups and except for the
manner in which anterior abdominal wall was dealt with,
In the recent years, many surgeons have advocated
the cholecystectomy was otherwise standard and same for
the use of a small 5-10cm incision in the subcostal
both the group. Incision length was kept less than 12cm.
area for cholecystectomy which is known as mini
cholecystectomy. This incision is similar to the Kocher’s Surgical Procedure: A transverse subcostal incision
incision except for the length of the incision12. The was used in all cases. Anterior rectus sheath was divided
major advantages of this incision are lesser in the line of the incision. Rectus muscle was cut along
postoperative pain, early recovery from the surgery the line of incision in a muscle cutting group, but in
and return to work and good cosmetic results 13. But a muscle splitting group rectus muscle was split bluntly
disadvantage is less exposure, which can be dangerous in the line of its fibers approximately 2.5 cm to the
right of linea alba. Rectus muscle was then retracted
in cases of difficult anatomy or lot of adhesions and
medially and laterally to expose the posterior rectus
chances of injury to bile ducts or other structures14,15. It
sheath which was then divided vertically and peritoneal
is the muscle division, which is supposed to be cavity entered in both of the groups. Intraoperatively,
responsible for postoperative pain and the resultant local the following parameters were measured: the operative
and systemic effects16. time calculated from the start of incision till the end
of surgical operation, and the amount of blood loss by
This study was undertaken to know whether the
weighing the blood-soaked mops and swabs both before
muscle splitting technique for open cholecystectomy
and after the procedure.
affects operative duration, blood loss, postoperative
pain, and encourages early mobilization with a reduction Postoperatively, we used visual analogue score
in hospital stay, and whether it relates to surgical site (after explaining it to patients) with 10 degrees to
wound infection or hernia compared with the traditional evaluate the severity of postoperative pain, both at the
rectus muscle dividing open cholecystectomy. night visit and
at the next morning visit. We also notified the duration Results
of hospital stay. Then, we followed the cases for six
weeks to check for signs of severe surgical site infection Patients were divided into two equal groups (60
and incisional hernia. Both groups were compared, and patients in each). In the group Demographics of patients
the results assessed statistically. were comparable in each group as shown in Table 1.

Table 1: Demographics of Patients in Both Groups

Females Males Mean age (years) P value
MCSI 42 18 41.6 0.07
MSSI 39 21 42.8 0.08

Regarding operative findings, the mean operative time in general was higher in group MSSI (92.7min), than in
group MCSI (86.4min), while the mean blood loss was much higher in group MSSI (12.3ml vs. 28.6ml), see table
below.

Table 2: Operative time and blood loss in both groups

Mean Operative Time (min) Mean Operative Blood Loss (ml)
Group MCSI 86.4 28.6
Group MSSI 92.7 12.3
P value* 0.001 0.001
Used two-sample t-test*

Postoperative pain was assessed for 3 days following surgery, and was noticed to be higher in group MCSI than
group MSSI, as following day 1 (3.44 Vs. 1.56), day 2 (1.78 Vs. 0.90), and day 3 (1.18 Vs. 0.76) as shown in Table
3.

Table 3: Mean visual analogue score for postoperative pain in both groups
Postoperative Days Visual score in MCSI Visual score in MSSI P value*
1 3.44 1.56 0.001
2 1.78 0.90 0.001
3 1.18 0.76 0.001
Used two-sample t-test*

We reported earlier hospital discharge for patients in group MSSI, that 49 patients (81.6%) were discharged at
the second postoperative day, in comparison to only 13 patients (21.6%) in group MCSI.

Most patients with group MCSI 28(46.6%) were discharged on the 3rd postoperative day, while only 9 patients
(15%) from group MSSI left the hospital on that day. On the other hand, the 4th postoperative day, all the remaining
patients from both groups were discharged home, as follows 19 patients (31.6%) and 2 patients (3.3%) from groups
MCSI and MSSI, respectively.

Table 4: Number of patients fit for discharge in both groups

Postoperative Days MCSI MSSI P Value*

2nd 13(21.6%) 49(81.6%) 0.001

3rd 28(46.6%) 9(15%) 0.006

4th 19(31.6%) 2(3.3%) 0.001
*Chi-square test was used.
Six weeks postoperative follow up showed a lower comparison to only 13 patients (21.6%) in group MCSI.
incidence of surgical complications in group MSSI. Thus group MSSI patients were fit for discharge earlier
Surgical site infection occurred in 7 patients (11.6%) in as compared to group MCSI patients. This was mainly
group MCSI, vs. 4 cases (6.6%) in group MSSI, while because of less pain and early mobility.
incisional hernia documented in 3 patients (5%) in group
MCSI, vs. just 1 patient (1.6%) in group MSSI, as Less postoperative pain encourages early
shown in Table 5. ambulation, earlier discharge from hospital and faster
return to work17. Baguley et al.16 reported that 100%
patients of muscle splitting group were fully mobile
Table 5: Six weeks postoperative complications in
by day 3 as compared to 75% patients with muscle
both groups
dividing group16. In this era of concern for the expense
MCSI MSSI P value* of health care delivery, strategies that reduce the length
Wound infection 7 4 0.38 of hospitalisation and decrease duration of disability
Incisional hernia 3 1 0.32 stimulate tremendous interest among the medical
and lay communities. The muscle splitting incision is
Chi-square test was used*
superior to muscle dividing incision in term of less pain,
early mobility, less physiological alteration, decreased
Discussion morbidity and hospital stay7,14.
In the present study observed that the blood loss Wound infection was shown to be more common in
in group MCSI is more than group MSSI, but with less group MCSI, most likely due to haematoma collection
overall postoperative time. Muscle cut is associated with following blood vessels division, besides local ischemia
division with all segmental blood vessels, and muscle that ensues. Wound infection is probably an important
fibers7. This may explain the increased blood losses.
risk factor for the development of incisional hernia and
Regarding shorter operative time in group MCSI, it’s
wound dehiscence8. The local nerves divided by the
likely due to the better access and view gained by
cut through incisions increase the possibility of having
muscle cutting8,16, which may be reflected in a shorter
postoperative incisional hernia17. Generally speaking,
duration required to accomplish the surgery.
transverse and oblique incisions seem to cause less
The patients of group MSSI experienced less wound dehiscence than the midline and paramedian
postoperative pain than those in group MCSI. Decrease incisions18. Yet, as the subcostal incision has an oblique
in pain is mainly attributed to the splitting of rectus medio- proximal direction, it tends to cut most nerves,
muscle rather division of muscle. When muscle is cut, segmental blood vessels and muscle fibres
many segmental blood vessels and nerves get divided perpendicularly. The partial denervation of the
which in turn make muscle spasm and leads to pain7,16. abdominal wall ensues with permanent muscle weakness
Merrill attributed less pain to intact vascularisation and and numbness7. Burger et al8, found that muscle-split
innervation of the muscle with splitting incision3. abdominal incisions cause less risk for wound
dehiscence than their muscle cut surgical wound
Baguley also reported that muscle splitting versions8.
technique appears to be superior in terms of
postoperative pain and discomfort to the muscle
Conclusion
dividing method16. Other authors reported similar results
in regard to less pain and even less postoperative The muscle split subcostal incisional can be suitable
analgesics requirements. Many authors reported that the for uncomplicated open cholecystectomy, with less
mean postoperative analgesic doses required for each blood loss, less postoperative pain, earlier discharge
patient is significantly less12. from hospital and less postoperative wound infection
Patients were considered fit for discharge when and less incisional hernia as compared to classical
they had no respiratory problem, moved bowel, no need muscle cut subcostal incision.
of regular intake of analgesics, took food and drugs Conflict of Interest: None
orally and were ambulatory7. In our study, 49 patients
(81.6%) were discharged at second postoperative day, in Source of Funnding: Personal
Ethical Clearance: The research belong to the tikrit 10. Keus F, Gooszen HG, Laarhoven CJHM,
university, college of medecin, department of surgery “Systematic Review: Open, Small-Incision Or
(all patients have written consent. Laparoscopic Cholecystectomy For Symptomatic
Cholecystolithiasis”, Aliment Pharmacol Ther.
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DOI Number: 10.5958/0976-5506.2019.01699.1

Association of Idiopathic IUGR with Placental Histological

Morphometry

Mohammed E. Ghanem1, Samia A. Eleiwe2, Nagham K. Tayeh3

Department of Anatomy, Histology & Embryology, Asst. Lect. Dr. Faculty of College of Medicine, Al-
1

Kindy College of Medicine, Baghdad University, Baghdad, Iraq; 2Department of Anatomy, Histology &
Embryology, Prof. Dr. Faculty of College of Medicine, Al-Mustansiriyah University, Baghdad, Iraq.
Staff Member of Gynecology and Obstetrics at Al- Khadraa’ Private Hospital, Baghdad, Iraq;
3
Department
of Obstetrics and Gynecology, Staff Member of Gynecology and Obstetrics Fatima Al-Zahraa Maternity
Hospital, Baghdad, Iraq

ABSTRACT
Background: Intrauterine growth restriction (IUGR) is a complex placental vascular disease with
augmented perinatal morbidity and mortality caused by various fetal, maternal as well as placental factors.
This study was conducted to find any association of whichever placental histo-morphometric findings to
encounter any sole placental based issues influencing fetal growth and development, which might be
derived from neither fetal nor maternal basis giving consideration for any probable analogous problem for
prospect pregnancies.
Method: Placentas of 100 IUGR newborns (group-I) and another 100 from normal body weight newborns
(group-II) were obtained between 2nd of February of 2018 and 31th of January 2019 to be studied histo-
metrically for the number of: nuclei of syncytiotrophoblast cells, syncytial knots, chorionic terminal villi,
blood vessels, and the perimeter and surface area of the villous sections, all were statistically evaluated.
Results: Morphometric data confirmed that placentas of group-I had significant higher number of
syncytiotrophoblasts nuclei, knots, terminal villi, blood vessels, terminal villi perimeter and cross-sectional
surface area than group-II.
Discussion: Encountered placental histological changes for idiopathic IUGR newborns raised suspicion it
was caused by pure placental factors and could be compensation to adjust the functional requirement during
placental insufficiency.
Conclusions: Newborns with idiopathic IUGR could be resulted from pure placental factors which might
be
ascertained by histological assessment of placental tissues.

Keywords: Idiopathic IUGR, Placenta, Terminal villi perimeter, Terminal villi cross surface area, Syncytial
knots.
Introduction Email: [email protected]

Intrauterine growth restriction (IUGR) is still a

significant problem worldwide 1, and problematical
placental vascular disease ensuing a low birth weight
and/or preterm delivery with increased
perinatal

Corresponding Author:
Mohammed E. Ghanem
Asst. Lect. at Al- Kindy College of Medicine,
Baghdad University, Baghdad, Iraq
morbidity and mortality 2-4. IUGR may be originated by
various feto-maternal and/or placental factors 2-5.

The placenta is the least celebrated human

appendage, yet an attractive model for global medical
investigations6&7. As placental growth is imperative in
the ultimate health of the mother and her fetus, a
complete knowledge about placental structures and
physiology is surely required 8 & 9.

After birth, the placenta could be regarded like

an investigational animal for wide assortments of
making inquiries 10. Nevertheless, it is the merely organ
944 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 944

recognized to be produced in parenthood, then gets 1×1×1 cm and was organized for schedule paraffin
a section to be fixed
distinctive fate11.
About its constitution; placenta has tissues, in
cooperation, from mother and fetus. The embryonic
surface, chorion, which is created by trophoblasts,
whereas the maternal surface is referred to as decidua
basalis. The trophoblasts take in cytotrophoblasts along
with syncytiotrophoblasts that build the chorionic
villi collectively to offer an exchange plane course.
Thousands of chorionic villi branching numerous times
to be soaked in maternal blood lakes for transmission of
gasses and nutrients 12 &13.

Material and Method

This work was carried out through Department
of Anatomy, College of Medicine, Al-Mustansiriyah
University, in assistance of Department of Gynecology
and Obstetrics at Fatima Al-Zahraa Administrative
Hospital, Al- Khadhraa Private Hospital and Al-
Yarmook Teaching Hospital in Baghdad, Iraq. Permitted
by the confined scientific committee of each of these
medical institutes. A total of 200 mothers, along with
their newborns and placentas were incorporated in this
study. These mothers were admitted to delivery room
for normal vaginal deliveries at these hospitals. All were
chosen at term pregnancy (of 38-40 weeks), and non-
smoker apparently healthy and normal women,
according to their history, clinical assessments,
laboratory tests and ultrasound check. Fetal state also
was verified by Doppler ultrasonic exam. Any mother
had difficult or delayed labor and any postpartum
maternal death also had been ruled out from this
work. A verbal consent was gained from each mother
to be a component of this work. All fetal IUGR was
considered to be idiopathic, given that there were no
apparent maternal or fetal basis.

Placentas were divided into two groups. Each group

consisted of 100 newborns with everyone own placenta.
The 1st group holds placentas of infants having
idiopathic IUGR (Group-I), whereas the 2 nd group
embraced placentas of infants having normal average
body weight (Group-II), which was regard as the control
group.

Placentas were right away examined grossly after

being expelled, and tissues were taken from the central
part of cotyledon at half way between the fetal surfaces
and maternal and at middle of the widest diameter
extending from the insertion of umbilical cord to the
periphery of placenta 11 &12. Every block was roughly
945 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 945
and stained by haematoxylin and eosin. Then, from
every tissue block five sequential sections of about 5 μm
thicknesses were obtained and inspected histologically
by light microscopy 14 &15. Morphometric histological
data were gained using computerized program
specifically, Motic Image Plus 3, at different
magnifications, and the estimated data of 6 histological
parameters were taken randomly from 5 fields achieved
from the center and four corners of each specimen, then
images were imprisoned in high clarity using the built-in
camera to obtain mean number of the followings
parameters: (1) nuclei of syncytiotrophoblasts, (2)
syncytial knots, (3) chorionic terminal villi and (4)
cross-sectioned blood vessels of the villous core. Then
after, three randomly selected terminal villi having
dissimilar sizes “small, medium and large” were
considered in every section and the following two
factors were anticipated: (5) mean perimeter of the
villous sections in μm and (6) mean villous surface area
in 1 μm2.

The estimated data were deliberated as mean ±

Standard deviation (SD), then by means of “Paired
Samples T- test” with the program namely “Statistical
Package for Social Sciences SPSS Statistics Version
25”. Statistical significance of the comparable variables
were evaluated and p value was equal or less than
0.0516.

Results

The morphometric data obtained from tissue images

at 400× magnification revealed the followings: As
shown in table 1 and figure 1, firstly, the nuclei of the
coating syncytiotrophoblasts zone of IUGR group
(Group-I) were significantly more packed than the
control group (Group- II), forming nearly a continuous
layer enveloping core of the villi. Secondly, the number
of syncytiotrophoblast knots at the peripheries of villi
was significantly superior in group-I too. Thirdly,
group-I have significant higher number of chorionic
terminal villi than group- II. In addition, there were
significant more villous connective tissue cells and
fibers, allowing diminutive intervillous spaces
surrounding these villi. Furthermore, the number of
blood vessels inside the core of villi was also
significantly higher in group-I than group-II with
extremely significant statistical difference. Lastly, the
mean perimeter and cross-sectional surface area of the
terminal villi was significantly higher in group-I too as
in table 1 and figures 2 & 3 respectively. All mentioned
mean differences between the groups were statistically
highly significant with p value extremely less than 0.05.
Table 1: No. of Syncytiocytotrophoblast’s nuclei, no. of Syncytiocytotrophoblasts knots, no. of villi and no. of
blood vessels in placental tissues of fetuses having IUGR (group-I) and fetuses having normal wt.
(control/group-II).

Histological parameters Groups N Mean ± SD p value

Group-I (IUGR) 100 14.567 ± 4.419
1. No. of Syncytiocytotrophoblast’s nuclei 0.0001
Group-II (Control) 100 9.132 ± 3.411
Group-I (IUGR) 100 2.014 ± .337
2. No. of Syncytiocytotrophoblasts Knots 0.0001
Group-II (Control) 100 0.912 ± .276
Group-I (IUGR) 100 11.209 ± 5.117
3. No. of Villi 0.0016
Group-II (Control) 100 9.132 ± 3.978
Group-I (IUGR) 100 6.311 ± 1.402
4. No. of blood vessels 0.0001
Group-II (Control) 100 4.576 ± 1.236
Group-I (IUGR) 100 143.612 ± 41.022
5. Perimeter of the villi in µm 0.0001
Group-II (Control) 100 112.004 ± 19.643
Sectional surface area of the villi in Group-I (IUGR) 100 11345.674 ± 236.127
6. 0.0001
µm2 Group-II (Control) 100 7558.142 ± 504.652

Figure 3: Sectional surface area of the villi in µm2

in placental tissue of fetuses having (group-I) and
fetuses having normal wt. (control/group-II).

Discussion

Placenta is still an imperative matter of interest

for medical researches 8&9, so it was preferred in the
Figure 1: No. of Syncytiocytotrophoblast’s nuclei, existing study. It is considered to be as a mirror for the
no. of Syncytiocytotrophoblasts knots, no. of villi fetal intrauterine state 17. The vital triangle consisted
and no. of blood vessels in placental tissues of fetuses of mother, fetus and placenta is regarded as an active
having IUGR (group-I) and fetuses having normal balanced milieu, hence, any harm to one of them would
wt. (control/group-II). surely influence the others 18&19. So many previous
studies had documented that a pure placental factor was
the solitary cause in some IUGR cases 20.

Normal birth-weight neonates were considered to be

the control group 21&22. In this revision cases of IUGR
due to apparent maternal and/or fetal factors were kept
out, hence the included cases of IUGR were considered
to be purely due to placental sources. Histological and
Figure 2: Perimeter of the villi in µm in placental morphometric studies of human placentas were looked
upon by many researchers just as a meandering approach
tissue of fetuses having IUGR (group-I) and fetuses
to study the histo-physiology of pregnancy 23. This study
having normal wt. (control/group-II).
included three varieties of villi, depending on previous presence of apparently average healthy mothers, could
comparable work 23. The program “Motic Image plus 3” be
which was used in this study, was exceptionally useful
to quantify the asymmetrical and compound
constitutions of the terminal chorionic villi pictures,
and evaluate the data in a mathematically balanced
method. Tissue samples were obtained just from the
cotyledon just at midway between the fetal and maternal
surfaces and in the middle of largest diameter between
the cord insertion and periphery, since this practice was
used by other workers, to stay away from any structural
tissue variation between subchorionic and parabasal
regions24&25.

By examination of haematoxylin and eosin stained

samples of mutually groups: Table 1 and figure 1
shows the syncytiocytotrophoblast’s nuclei number
was found to be increased in group-I, which might
be as a compensatory means to tolerate placental
insufficiency 26. It had been stated that there is a higher
syncytiocytotrophoblast’s nuclei number in cases of
stillbirth, poor fetal outcome and low birth weight 27&28.
Also augmented number of syncytial knots in group-I
similar as results noticed in pre-eclampsia, toxaemia of
pregnancy and idiopathic intrauterine growth retardation
29
. Profusion of syncytial knots are usually regarded
as an indicator of oxidative stress in consequence of
deprived fetal circulation 28. The greater number of
larger terminal villi containing more connective tissue
cells and fibers in group-I which possibly be caused by
diminished fetal villus perfusion producing activation
and proliferation of fibroblasts within villous stroma 28
& 30
. The increased number of blood vessels in placentas
within the villous core of group-I, which was regarded
as a placental compensatory response to recover chronic
low down blood perfusion and hypoxia 29 & 30. Table
1 and figure 2 showed that the mean of perimeters
of villous sections was increased in group-I which
represented the feto-maternal substitution surface mimic
what is seen in placentas of diabetic pregnant
mothers
31
. Table 1 and figure 3 illustrated larger cross-sectional
surface area, in placentas of group-I. This surface area
signifies the crossing point for substitution between fetal
and maternal flow, therefore, it is a milieu of medical
investigate till now 29. The instantaneous data in group-I
were comparable to that of interruption in placental
tissue maturation and they were just as compensatory
mechanisms to get better placental function 29 & 31. It
might be concluded here that idiopathic IUGR, with the
due to pure placental factors which might be ascertained
by histological assessment of placental tissues.

Such study was assumed to view a number of

morphometric histological microscopic modifications
in the placenta, in casing of wholesome placental cause
of IUGR in order to take care of the future pregnancy
and to prevent as much as possible such similar IUGR
condition for maintenance of fetal and mother optimal
wellbeing as well as decreasing neonatal loss. Moreover,
this instant results might confirm the idea of existence of
a remarkably related “birth triangle”; formed of fetus,
placenta plus mother 32.

Ethical Clearance: Approved and granted from Al-

Mustansiryia University, Al-Rusafa and Al-Karkh health
Directorate application forms as a requirement to obtain
PhD degree in Anatomy, Histology and Embryology.
Research projects are reviewed and conducted ethically.
This research is not published yet.

Source of Funding: This study was self-funded.

Conflict of Interest: The authors declare that they have

no conflict of interest

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Rainer Wachtveitl, Nada Cordasic, Wolfgang
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DOI Number: 10.5958/0976-5506.2019.01700.5

Evaluation of Polycystic Ovarian Syndrome Women as a

Result of Clomiphene Treatment

Zainab Abdul wahed Naji

MSc, Clinical Biochemistry, Al Iraqia University, Baghdad, Iraq

ABSTRACT
Polycystic ovary syndrome (PCOS) is a disorder that affects a woman’s hormone levels Clomiphene citrate
is used generally as an initial treatment. In the present study, LH, FSH, testosterone, progesteron and
oestrogen were analysed for the women undergoing clomiphene in Iraq. Total 73 infertile PCOS women
(age ranging from 19-33) were enrolled in the study and they were divided into 3 groups depending on the
clomiphene treatment where, group 1 patients (n=21) were given 50mg, group 2 (n=23) were given 100mg
and group 3 (n=28) were given 150mg dose of clomiphene. The serum leutinizing hormone and
testosterone found to be decreased after treatment, while follicle stimulating hormone and estrogen showed
the opposite trend. When various parameters are studied such as ovary size, number of follicles,
endometrium layer, it was found that, ovarian size after treatment they are decreased but did not show any
significant difference.

Keywords: Polycystic ovary syndrome, clomiphene, leutinizing hormone,

testosterone
Introduction The polycystic ovary syndrome (PCOS)
approximately accounts for 75% of the cases and is
Infertile women about 20-40% are having ovulatory
the commonest cause of anovulatory fertility 6. In the
disorders and PCOS is the most common cause of patients with PCOS the first agent to be introduced in
ovulatory dysfunction, which represents general practice for ovulation induction is clomiphene
approximately citrate (CC) and is still considered the first therapeutic
70% of cases1,2. Clomiphene citrate is used generally option for PCOS7. The choice of clomiphene is because
as an initial treatment3. Clomiphene citrate utilization relatively safe nature, can be administered easily, and is
shows discrepancy between the high rates of ovulation inexpensive. It is important to know that the first line
(60-85%) and the much low rates of conception (20- treatment is diet and exercise8-10. Women with PCOS
40%) per cycle1,4. In case of pregnancies where we use shows various metabolic disorders including increased
clomiphene citrate, 7-13% shows multiple gestations1,2,4. serum levels of luteinizing hormone (LH), testosterone,
The women taking Clomiphene citrate shows certain and prolactin which could influence women health in
common side effects such as 20% vasomotor symptoms, long term11-13. The clomiphene citrate with an injection
5% adnexal tenderness, 3% nausea, 1% headache, of human chorionic gonadotropin administration is
and rarely blurring of vision of scotoma2. The ovarian one of the most common therapies 14. In women with
hyperstimulation syndrome (OHSS) incidence in PCOS clomiphene is used to improve ovarian function,
patients treated with clomiphene citrate is rare, but it menstrual pattern and glucose metabolism15-16.
may lead to multiple follicular development with OHSS
risk and in patients with PCOS shows multiple Estrogen compounds and clomiphene have structural
similarity which may have negative effect on endometrial
pregnancies1,5.
thickness16-17. For the treatment of infertility in male
Corresponding Author: clomiphene citrate is most commonly prescribed. In the
Zainab Abdul Wahed Naji hypothalamus and pituitary, clomiphene citrate which is
MSc, Clinical Biochemistry, synthetic nonsteroidal drug which acts as an antiestrogen
Al Iraqia University, Baghdad, Iraq and competitively binds to oestrogen receptors. The
Phone: 07700126197 normally low levels of oestrogen on the male hormone
Email: [email protected] axis are blocked which results in increased secretion
950 Indian Journal of Public Health Research
Indian & Development,
Journal JulyResearch
of Public Health 2019, Vol.10, No. 7
& Development, July 2019, Vol.10, No. 7 950

of GnRH, FSH and LH. These hormone’s enhanced in the Microsoft excel program and graphpad prism 5
output increases testosterone production and sperm (version 5.01).
production18. In the present study, LH, FSH,
testosterone, progesteron and oestrogen were analysed Results
for the women undergoing clomiphene in Iraq.
In the present study we took total 73 infertile
Material and Method patients with age ranging from 19-33. These all patients
are suffering with polycystic ovary syndrome (PCOS).
Enrollment of the Patients: Total seventy three These are divided into 3 groups depending on the
infertile patients (age 19-33) with polycystic ovary clomiphene treatment where, group 1 patients (n=21)
syndrome (PCOS) were enrolled in the present study. were given 50mg clomiphene, group 2 (n=23) were
Oral consent was obtained before enrollment. given 100mg and group 3 (n=28) were given 150mg
Treatment of Clomiphene: The enrolled patients dose of clomiphene. The blood was collected before
were randomly divided into three groups on the bases (pre-treatment sample) and after (post-treatment sample)
of their clomiphene treatment. The patients were given treatment to check its effect. Luteinizing hormone, FSH,
Clomiphene at various doses such as 50mg (n=21), Testosterone, progesteron and oestrogen from blood
100mg (n=23) and 150mg (n=28). Serum of all patients was studied. The serum leutinizing
hormone and follicle stimulating hormone are
Blood Collection and its Separation: The blood was determined it is found that before treatment the LH
collected before (pre-treatment sample) and after (post- levels were high which fall after the treatment and they
treatment sample) treatment to check its effect. The shows significant level of difference. As the
collected samples were centrifuged at 3000 rpm for 10 concentration of clomiphene is increased level of LH
minutes, and serum was separated within 30 minutes
shows difference i.e. low value. It shows that high
from the time of blood collection. Serum was aliquots in
concentration of clomiphene (150 mg) shows high level
an Eppendorf tube and frozen in the deep freeze at -40°C.
of significance.
Serum of all patients was subjected for the
When serum FSH was determined we can find
estimation of the luteinizing hormone and FSH
estimation. The estimation of Testosterone, progesteron that FSH levels were low before treatment and which
and oestrogen were carried out as per manufacturer’s increases after treatment. The clomiphene concentration
instructions (VIDAS® system, Biomerieux, Italy). at 150 mg shows increase in FSH levels but show non-
significant difference. When LH and FSH ratios are
Statistical Analysis: The results were represented as calculated together clomiphene concentration at 150 mg
mean ± Stand error (n=21). The data were shows good results i.e. lowered level of both LH and
processed
FSH, and hence shows significant level of difference.

Figure 1: Serum LH and FSH levels and their ratio

We also analyzed the testosterone, progesterone, oestrogen levels, we found that before treatment the
testosterone levels were high, which get lowered after the clomiphene treatment, which showed significant
difference. The oestrogen levels were low before treatment which are increased after treatment, where concentration
of clomiphene did not show any significant difference but after treatment if compared to before treatment, all the
concentrations shows significant difference level.

Figure 2: Serum testosterone, progesterone and estrogen levels

When various parameters are studied such as ovary size, Number of follicles, Endometrium layer, it was found
that, ovarian size after treatment they are decreased but did not show any significant difference. When number
of follicles is determined before and after treatment it showed significant difference. Endometrium layer when
determined showed non-significant difference level.

Table 1: Effect of various concentrations of clomiphene on ovary size, number of follicles and endometrium
layer
Parameter Treatment 50mg 100mg 150mg
Before 17.14 ± 1.19 16.06 ± 1.12 15.39 ± 1.59
Ovaries size
After 14.25 ± 1.79 14.01 ± 1.81 13.64 ± 1.63
Before 13.90 ± 1.86 13.13 ± 1.35 13.71 ± 2.08
Number of follicles
After 18.33 ± 1.15 17.47 ± 0.94 17.53 ± 0.744
Before 4.29 ± 1.10 3.52 ± 1.47 4.14 ± 1.11
Endometrium
After 6.45 ± 0.57 6.58 ± 0.95 6.4 ± 0.70

Discussion In the present study, we found nonsignificant

difference in FSH and significant difference in LH.
In the present study total 73 patients with age
Where, Sheikh-El-Arab et al19 found significantly
ranging from 19-33 were selected. All these patients
higher values of FSH (p-0.02), and had significantly
are suffering with polycystic ovary syndrome (PCOS).
thicker endometrium (p-0.02). Rebecca et al20 found
These are divided into 3 groups, group 1 patients (n=21)
that significant increase in LH and FSH levels in the
were given 50mg clomiphene, group 2 (n=23) were
clomiphene citrate group if compared with control
given 100mg and group 3 (n=28) were given 150mg
group (P<0.01: P<0.02). Serum thyroid levels in CC-
dose of clomiphene. Further blood samples are drawn
treated group is higher as compared to the placebo group
and tested for serum FSH, LH levels and testosterone,
(P<0.01).
progesterone and estrogen levels are determined.
Safeer et al21 found that serum testosterone showed or idiopathic hirsutism. Brithis Medical Journal
highly significant increase (P<0.05), serum FSH showed 1986, 293, 355–359.
non- significant increase which is same like present
7. Thessaloniki ESHRE/ASRM- sponsored PCOS
study report. Gonzales et al22 showed highly significant
consensus workshop group. Consensus on
increase in the testosterone serum level (P<0.05), and
infertility treatment related to polycystic ovary
increase in mean serum level of FSH (P<0.1).
syndrome, Fertil Steril 2008; 89 (3): 505-522.
Shekoufeh et al23 found that, in some experiment 8. Crosignani PG, Colombo M, Vegetti W.
group FSH significantly reduced if compared to control Somigliana E. Gessati A. Ragni G. Overweight
and in group (p<0.001). The results also showed that and obese anovulatory patients with polycystic
estrogen level was increased significantly in all groups ovaries: parallel improvements in anthropometric
(p<0.001). Also, the progesterone levels in all groups indices, ovarian physiology and fertility rate
decreased significantly if compared to control (p<0.001). induced by diet. Human Reproduction 2003,
Kerin et al24 and Dicky et al25 also found similar results 18,
like present study. 1928–1932.

Ethical Clearance: The blood was collected from AL_ 9. Norman RJ, Noakes M, Wu R, Davies MJ, Moran
Numan hospital after their investigation. Oral consent L, Wang JX. Improving reproductive performance
was taken before enrolled the patients in the study. in overweight/obese women with effective weight
management. Human Reproduction Update 2004,
Source of Funding: Self 10, 267–280.

Conflict of Interest: Nil 10. Pasquali R, Gambineri A. Role of changes in

dietary habits in polycystic ovary syndrome.
Reproductive BioMedicine Online 2004, 8, 431–
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DOI Number: 10.5958/0976-5506.2019.01701.7

Variance Analysis of Acute Myocardial Infarction Clinical

Pathway in The Era of National Health Insurance

Fadlia Fardhana1, Kurnia Sari2, Atik Nurwahyuni2

1
Post Graduate Student of Public Health, Department of Health Policy and Administration, 2Department
of Health Policy and Administration, Faculty of Public Health, Universitas Indonesia

ABSTRACT
Acute myocardial infarction (AMI) was responsible for 7.4 million deaths worldwide and could cause
complications, disability, productivity loss with high cost. Since Indonesia has implemented the National
Health Insurance, cost efficiency in maintaining clinical practice quality is needed. Clinical pathway is a
tool for maintaining quality of clinical process and cost by setting intervention based on time and sequence.
Analysis of variance was carried out to evaluate the implementation of clinical pathway. Data from medical
and billing record were reviewed and analyzed by Clinpath Evaluation Tool version 2.0. Characteristic of
patient, average utilization of medical treatment and clinical tests, and drugs utilization were obtained from
this tool. Hospital has played a good role in maintaining quality of health services. This can be seen from
the accordance between clinical practice and clinical pathway in majority of the medical treatments and
drugs administration. Average length stay was 4.65 days with the median of 6 days, and this was close
enough with clinical pathway. Administration of oxygen and isotonic fluid were the highest average
utilization in clinical practice. Nitrate and anti-platelet were the major drugs used in medication. Wide
variations only occurred in laboratory tests (variation: 86.96%) and should be evaluated, considering
variation could affect quality of services and moreover on the cost of treatment.

Keywords: clinical pathway; myocardial infarction; implementation pathway; variance

analysis.
Introduction The new Health Insurance in Indonesia brought
challenge to health care provider. Health care provider
As Indonesia has been entering the era of National
needs to use resources efficiently to reduce service’s cost
Health Insurance in 2014, the quality of health services
while still maintain the quality in patient care. Clinical
while maintaining cost efficiency became one of the
pathway is one of the most popular disease management
biggest issues in health care delivery. The National
tools to overcome this problem3. Clinical pathway
Health Insurance in Indonesia introduced new health
provides sequence and timing of healthcare
care financing policy from fee for service to case-based
practitioner’s intervention to achieve outcome therapy
scheme. This financing method was called Indonesian
with optimal efficiency4sequencing and timing of
Case Base Group (INA-CBG) tariff and based on the
interventions by healthcare professionals for a
Minister of Health Regulation number 52 and 64, 2016.
particular diagnosis or procedure. It is a relatively new
INA-CBGs uses codification system from diagnosis
clinical process improvement tool that has been
and clinical procedure or clinical pathway from certain
gaining popularity across hospitals and various
disease1,2.
healthcare organisations in many parts of the world. It is
now slowly gaining momentum and popularity in Asia
and Singapore. Clinical pathways are developed through
Corresponding Author: collaborative efforts of clinicians, case managers,
Kurnia Sari nurses, and other allied healthcare professionals with the
Department of Health Policy and Administration, aim of improving the quality of patient care, while
Faculty of Public Health, Universitas Indonesia minimising cost to the patient. Clinical pathways have
Email: [email protected] been shown to reduce unnecessary variation in patient
care, reduce delays in
955 Indian Journal of Public Health Research
Indian & Development,
Journal July
of Public Health 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 955

discharge through more efficient discharge planning, pathway12. Deviation in this study includes variation
and improve the cost-effectiveness of clinical services. of length of stay, timing of intervention, and drugs
The approach and objectives of clinical pathways are administration. The purpose of this study is to present
consistent with those of total quality management clinical practice variance for acute myocardial infarction
(TQM. Research in Hong Kong and Singapore stated as basic evaluation of the clinical pathway.
that the implementation of clinical pathway for AMI
impacted the decreasing length of stay variation, Material and Method
mortality rate, and complication rate 4sequencing and
timing of interventions by healthcare professionals for This research was conducted in private hospital in
a particular diagnosis or procedure. It is a relatively new Bogor. Data were collected prospectively from medical
clinical process improvement tool that has been gaining record and billing unit from October 2016 to March
popularity across hospitals and various healthcare 2017. Medical record and billing unit in hospital
organisations in many parts of the world. It is now provided patient’s data recapitulation digitally, and then
slowly gaining momentum and popularity in Asia and the recapitulated data became the data source in this
Singapore. Clinical pathways are developed through study. Date of birth, sex, payment method, and date of
collaborative efforts of clinicians, case managers, patient’s admission and discharge were gathered from
nurses, and other allied healthcare professionals with medical record. Doctor specialist visit (frequency of
the aim of improving the quality of patient care, while doctor’s visit), medical treatment, laboratory test,
minimising cost to the patient. Clinical pathways have radiology, and drugs administration were gathered from
been shown to reduce unnecessary variation in patient billing record.
care, reduce delays in discharge through more efficient
All inpatient acute myocardial infarction with
discharge planning, and improve the cost-effectiveness code ICD-10 I21.9 were included in this stud y. An
of clinical services. The approach and objectives of exclusion criterion was an inpatient that had secondary
clinical pathways are consistent with those of total diagnosis. All data recapitulations were analyzed by
quality management (TQM,11. Other research also found Clinical Pathway Evaluation Tool version 2.0. This
that implementation of clinical pathway can decrease tool is in public domain. The information that can be
clinical practice variation and cost of treatment5,6acute obtained from this tool were characteristic of patient
myocardial infarction (AMI. (age, sex, payment method, and length of stay), average
utilization of medical treatment and clinical tests, and
Acute myocardial infarction (AMI) is one of the
drugs utilization. Analysis variance were carried out
manifestations of coronary heart disease (CHD) and
by comparing average utilization and standard clinical
part of cardiovascular diseases (CVDs). Cardiovascular
pathway in hospital.
diseases were the cause of 31% deaths globally and 17.7
million people were estimated to die from CVDs in
2015. Among the 17.7 million, 7.4 million deaths were Result
caused by coronary heart disease7. In Indonesia, General Characteristic: There were 233 patients
coronary heart disease is the highest cause of death, with acute myocardial infarction from October 2016
which was the cause of 14.2% deaths in 2016 8. to March 2017. Patients that had secondary diagnostic
Coronary heart disease became the global burden and were excluded and 10 patients were left to be analyzed.
also impacted the economy. In United States, Among 10 patients, 8 patients were male (80%) and 2
myocardial infarction caused patients were female (20%) with the average age of 60.2
1.1 million hospitalizations and costed at least US$ 450years old (range from 42-75 years old). 90% patients
billion9. Besides death, AMI can cause complications, choose National Health Insurance as their payment
disability, and productivity loss10. method and 10% patients payed privately. Average
Clinical pathway should be evaluated constantly length of stay (ALOS) was 4.65 days with the median of
to maintain quality from the healthcare provider. 6 days (range from 2-7 days).
Variance analysis could be used to evaluate and analyze
Medical Treatment Utilization: Utilization can be
the implementation of clinical pathway. Variance is
interpreted as the amount of clinical practice that were
clinical practice deviation from the standard in
given to all patients from patient’s admission to
clinical
discharge
or per one period of care. Medical treatment variation was Conted…
cardiopulmonary resuscitation. The highest average
utilization was administration of isotonic fluids and Angiotensin
Receptor + 1.1
the lowest was ECG diagnostic, which were 14.8 and
Blocker (ARB)
1.0, respectively. Other average utilization of medical
Anti-anxiety + 3.1
treatment can be seen in Table 1.
Laxative + 0.8
Gastroprotective
Table 1: Medical Treatment Utilization - 2.1
drugs
Utilization Average Diabetes drugs - 1.5
according to Utilization Antibiotic - 0.4
Medical Treatment
the clinical in clinical Anti-
pathway practice - 0.5
hypertensive
ECG diagnostic 1.0 1.0 Diuretics - 0.6
Oxygen delivery 3.0 7.6 Laboratory and Radiology Utilization: The laboratory
IV isotonic fluid 7.0 14.8 test that was included in clinical pathway was only
ECG serial 5.0 5.3 troponin test. Troponin test was used as diagnostic test
Specialist’s visit 7.0 6.5 to diagnose AMI. But according to data, laboratory tests
that were received by patient were not only troponin
Vital sign monitoring 7.0 3.9
test, but also routine blood test, creatinine, urea nitrogen
Cardiopulmonary
- 0.1 (BUN), glucose test, test for Na, K and Cl, HDL, LDL,
resuscitation
Drugs Utilization: The main principal for AMI total cholesterol, SGOT and SGPT. Radiology was not
included in clinical pathway, but there was radiology
medication is to restore blood flow in blood vessel to the
utilization for thorax. Laboratory and radiology average
heart as soon as possible. Drugs that were used
utilization are presented in Table 3.
according to the clinical pathway were drugs from
classification of nitrate, anti-platelet, anti-coagulant,
statin, beta blocker, ACE inhibitor, angiotensin receptor Table 3: Laboratory and Radiology Utilization
blocker (ARB), antidepressant, and anti-inflammatory Utilization Average
steroid. Beside drugs that were included in clinical according to Utilization
Laboratory
pathway, patients were also given other drugs such as the clinical in clinical
gastroprotective drugs, drugs for diabetes, antibiotic, pathway practice
anti-hypertensive and diuretics. This study only included Troponin T 1.0 0.6
patients that did not have secondary diagnosis, but Blood test - 1.0
evidently there were still some other drugs that were Creatinine - 0.6
given to patients. Average utilization for medication was BUN - 0.6
presented in Table 2. Glucose test - 0.6
Na, K, Cl - 0.2
Table 2: Drugs Utilization HDL and LDL - 0.4
Utilization Average Total cholesterol - 0.4
Drugs according to Utilization SGOT and SGPT - 0.2
Classification the clinical in clinical Thorax - 0.2
pathway practice
Nitrate + 28.5
Anti-platelet + 17.0 Discussion
Anti-coagulant + 3.1
AMI is caused by reduction of blood flow to the heart. Reduction of blood flow was caused by atherosclerosis
Statin + 3.0
and vasoconstriction13. Average Length stay (ALOS) for
β-blocker + 2.3
AMI patient in hospital was in the range of 6-7 days. In for isotonic fluid was 14.8, with the range from 0.2
this study, ALOS was 4.65 days with the median of 6 to
days. ALOS was shorter than length of stay in clinical 4.2 per day. Administration of isotonic fluid was also in
pathway, but from the median, it can be indicated that accordance with the clinical pathway and each patient
most patients were treated in hospital for around 6 days, was administered with it at least once per day.
and this was in accordance with the clinical pathway.
Drugs for AMI patients were delivered during
The compliance for length of stay was 70%. Average
patient’s stay and after the patient’s discharge. Major
utilization of specialist’s visit was 6.5 meanwhile
treatment for patient during hospital stay was the
the average length of stay was 4.65. This means that
combination of anti-platelet aspirin, nitrate and statin.
specialist could visit patient more than once per day.
Anti-platelet P2Y12 inhibitor (e.g. clopidogrel) and
AMI can be detected by analyzing troponin. anti-coagulant can be added as major treatment for
Troponin is a biomarker that will increase in blood level patients depending on patient’s condition. Morphine and
in myocardial ischemic condition. Patients with chest β-blocker also considered to be delivered for relieving
pain for 20 minutes or more and wasn’t getting better chest pain13,14. In AMI clinical pathway, patients got
after the nitroglycerin was delivered, were suspected to combination of dual anti-platelet (aspirin and P2Y12
have AMI. Patients then will get ECG diagnostic to inhibitor), anti-coagulant, and statin as major treatment
decide immediate treatment9,13,14. In clinical pathway, and it is slightly different from the literature. Drugs from
AMI was detected by chest pain, ECG, and troponin. the classification of ACE inhibitor, ARB, β-blocker,
ECG diagnostic should be done once but troponin test nitrate, morphine, laxative, and anti-depressant were for
was conditional in the first day of patient admission. conditional utilization. Meanwhile drugs that were given
Average utilization of ECG diagnostic and troponin test after the patient was discharged were dual anti-platelet,
were 1.0 and 0.6. If every patient received ECG nitrate, statin, ACE inhibitor, ARB, or β-blocker.
diagnostic and troponin test for one time, then the
The highest drug utilization was drugs from nitrate
average utilization should be 1.0 in the first day
and anti-platelet classification, which were 28.5 and
admission. The compliance of ECG diagnostic was
17.0, respectively. Anti-coagulant (utilization 3.1) and
100%, while compliance of troponin test was 66.67%.
statin (utilization 3.0) were the third and fourth highest
The variance of troponin test occurred because there
but their total utilizations were far from nitrate and anti-
were patients who took troponin test in second day of
platelet. From the utilization, it can be indicated that
admission while in clinical pathway, patient could not this result was different than clinical pathway. Dual
take troponin tests in the second day of admission. anti-platelet, anti-coagulant, and statin should be the
During treatment, vital sign and ECG should be highest utilization because they should be administered
monitored every day until the patient is discharged. to patients every day until the patient is discharged.
Average utilization for vital sign and ECG were 3.9 and ALOS was 4.65, therefore if patients at least received
5.3, respectively. This indicates that some patient got drugs once per day, drugs utilization should be 4.65. But
ECG monitoring for more than once per day. This was from the result, drug utilization for anti-coagulant and
likely because AMI patients were treated in ICU or statin did not reach 4.65 and this means that patients did
HCU room and need to be monitored closely. Oxygen not receive anti-coagulant and statin every day. Drugs
utilization might be different than the clinical pathway,
and isotonic fluids also were administered during
but actually in accordance with literature. Literature
treatment. Oxygen should be administered for the first
stated that nitrate could be given as major treatment, and
three days since admission and the rest days were
practically nitrate was highly given to patient.
conditional. Meanwhile isotonic fluids should be
administered every day until the patient is discharged. There were patients who received gastroprotective
Average utilization for oxygen administration was drugs, antibiotics, diabetes drugs, and anti-hypertension
7.6 and average utilization for the first three days and edema drugs. These drugs were not listed in
ranged from clinical pathway therefore it is considered as variations.
1.3 to 3. This signifies that oxygen administration was in Furosemide was known as medication for heart failure.
accordance with the clinical pathway, and oxygen was Heart failure was usually caused by myocardial damage
delivered for more than once per day. Average and the consequence of arrhythmia or other
utilization ventricular
complications. Alongside with other anti-hypertensive Acknowledgement
drugs such as amlodipine, furosemide also used for
hypertensive patients13,15,16. This study only included This research was supported by Directorate of
patients who did not have secondary diagnosis, but Research and Community Empowerment Universitas
practically there were patients who received anti- Indonesia.
hypertension, edema, antibiotics and diabetes drugs.
Conflict of Interest: The authors declare that they have
This means that there were patients who had diabetes,
no competing interest.
hypertension or heart failure and infection during
treatment in hospital. Source of Funding: This research was funded by
Directorate of Research and Community Empowerment
As for gastroprotective drugs, there are literature
that stated using these drugs for handling adverse drugs Universitas Indonesia through grant program for
reaction. Adverse effect of anti-platelet drugs is an students who conducted research, which was called
increased risk of bleeding, commonly in gastrointestinal International Indexed Publication and Students’ Thesis
(GI) tract. Gastroprotective drugs such as proton pump Grant with grant letter number
inhibitor (e.g. pantoprazole and omeprazole) can be used 2180/UN2.R3.1/HKP.05.00/2018.
to ameliorate GI tract17,18anesthesiologists encounter
many patients who are receiving drugs that affect Ethical Clearance: This research has passed ethical
platelet function as a fundamental part of primary and clearance from Faculty of Public Health Universitas
secondary management of atherosclerotic thrombotic Indonesia, with ethical clearance number 670/UN2.F10/
disease. There are several antiplatelet drugs available for PPM.00.02/2018.
use in clinical practice and several under investigation.
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DOI Number: 10.5958/0976-5506.2019.01702.9

Indoor Particulate Matter (PM10) and Health Risk on Junior

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P schools was estimated to inflict health risk
a therefore it needed to be maintained at a
k safe threshold of 0.142 mg/m3. This study
p concluded that indoor air quality in all
a junior high schools was poor and estimated
h to inflict health risk on students.
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Department of Environmental Health, Faculty of s
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Public Health, Universitas Indonesia, Depok, West ;
Java, Indonesia
s
c
A h
o
B o
S l
T ;
R
A s
C t
u
T d
Poor indoor air quality is found to be related to the e
prevalence of respiratory disorders in children. n
School t
aged children spend 6-8 hours in classroom. I
Therefore, air quality and its health risk in Indoor air pollution
classroom need to
n
t is found to be higher
be considered. In this study, in three junior high 10 r than outdoor and
we measured the level of schools and its health risk 10

PM o associated with
assessment. The d various respiratory
in three schools were10 0.215 mg/m3,
mean level of 0.075 mg/m3, 0.229 mg/m3 u diseases. The high rate
indoor PM c of indoor air pollution is
respectively. The in two schools was10higher than in two t
related to around 2
level of indoor outdoor. The exposure of PM i
PM o
n
million deaths in the prevalence of asthma in In Depok, the and its health risk on
prevalence of students of junior high
developing countries and the 5-14 years old children school to
4% of global disease burden. asthma (6.4%) was
was 4.6%12. Children are encourage
Poorly ventilated rooms found higher than the
susceptible to air pollution environmental health
province and national.
cause indoor and outdoor due to higher respiratory management in school
Particularly,
pollutants to accumulate frequency and physical t
indoors from time to time1,2. activity, also development
10
h
Nowadays, humans spend Corresponding a
of the respiratory system
most of their time Author: t
related to puberty1,13. This
indoors . One common
2-4
group spends 65-90% Bambang Wispriyono s
indoor air indoors, including 6-8 Department of u
hours in classroom1,14,15. Environmental Health, i
Classrooms tend to have four Faculty of t
Public Health, s
times higher occupancy
density than offices, Universitas
Indonesia, s
inadequate ventilation, and t
building conditions increase Depok, West u
the risk of more polluted air. Java, Indonesia d
Identification and control of Email: [email protected] e
n
indoor pollution will
t
reduce both short and
pollutan . The level of long-term health
t is PM health 10risk due to c
PM impacts1,14,16. Hitherto, there h
has not
exposure in classrooms is a
found to be associated been exposure and
r
with research its health risk
a
the prevalence of on PM on 10
c
respiratory disorders such
as asthma, st t
u e
de r 10
nt
s i
of s
ju t
ni
or i
hi c
g .
h
sc
h
o M
ol e
in
In t
d h
o o
ne
si d
a.
T Health risk
he
re assessment was
fo conducted by
re referring
,
wheezing, bronchitis, lower to the Risk
respiratory tract infections, it is important to study in
the exposure of PM schoo Assessment and
and impaired lung function ls Management
in children3,5-8. In addition,
lung development in Handbook
exposure to particulate children9-11. 199617,18. The sampling
matter was also reported to locations were 10
affect
classrooms
10
and three
fields from three junior high
schools, randomly selected.
The concentration of PM
was measured using
DustTrak™ II Aerosol
Monitor 8532 for one hour
each point. The size of
ventilation openings and
classroom
961 Indian Journal of Public Health Research
Indian & Development,
Journal July
of Public Health 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 961

were measured. A survey of 357 junior high school on an annual guideline of PM , the default of exposure
10
students was conducted to obtain data of body factors for adult recommended by U.S. EPA 201418, and
weight, the Exposure Factors Handbook 201119. The annual
height, and activity pattern that represent the population
10
of junior high school student in Depok. The weight guideline of PM is 0.5 mg/m3, according to the National
and height was also measured. The activity pattern was Ambient Air Quality Standards 10(NAAQS) U.S. EPA
in
collected through questionnaires to obtain the frequency 1997. The reference value of PM safe intake obtained
of exposure and duration of exposure. The concentration was 0.009 mg/kg/day. Then the risk management for the
of PM , activity pattern, and body weight were used in population was conducted if HQ > 1 by calculating
10
a
equation 1 to obtain chronic daily intake of PM10 (CDI, safe threshold value for PM based on the mean and the
10
mg/kg/day). 10th percentile of the students body weight.
Equation 1:
Results
C×R×t × f ×
D E E E
CDI = PM Concentration: The selected schools are
Wb × tavg
The mean concentration of indoor PM10 (C, mg/m3) located
10
in different sub-districts, namely Cimanggis (school
was analyzed for each school. The inhalation rate (R, m3/ A), Tapos (school B), and Beji (school C). The
hour) of the students was based on inhalation rate of 11- mean
16 year olds, 15.7 m3/day19. Junior high schools in Depok percentage of V/C in three schools was 14.39%, 14.50%
city apply school hours 6 hours/day (tE, hour /day), 5 and 29.65%, did not differ statistically. Regulation of
days/ week. Based on the 2017/2018 academic calendar Health Minister of Republic of Indonesia No. 1429/2006
set by the West Java Education Office, school days on Requirements of Environmental Health in School
were 218 days/year, including the exam days which sets the percentage of V/C in classroom at 20%. The
then reduced by the mean of absence day according to concentration of PM10 in three schools was shown
the survey to obtain frequency of exposure (fE, Table 1, the highest concentration of indoor PM10 was
day/year). Duration of exposure (D ) based on the found in school C, located in the city center with busy
E
compulsory period of junior main highway was 0.229 mg/m3. The concentration
of 10
high school education, 3 years. The mean of student body indoor PM between the three schools was statistically
weight (Wb, kg) was obtained. The average daily period significant (p = 0.000). Measurement of indoor and
10
of carcinogenic exposure was duration of exposure outdoor PM was carried out at different hour but
for the
365
dailydays per year (tavg, ED x 365 days/year). The same day. The highest value of I/O PM10 was found in
intake value would be used for the calculation of Hazard school A, 3.12 and statistically significant (p =
0.000).
Quotient (HQ) using equation below. 10
The level of measured PM were compared with several
Equation 2: guidelines, i.e. National Ambient Air Quality Guidelines
(NAAQS) U.S. EPA, WHO air quality guidelines,
CDI Government Regulation of Republic of Indonesia
HQ =
RfC No.41/1999 on Environmental Management (PP RI No.
The RfC value of PM10 was not provided by 41/1999), Regulation of Health Minister of Republic of
Integrated Risk Information System (IRIS) so Indonesia No. 1077/2011 on Guideline for Air Sanitation
this in House (Permenkes RI No. 1077/2011).
research used a safe daily intake reference value
based
Table 1: The Concentration of PM10 in Three Schools

School Guidelines
962 Indian Journal of Public Health Research
Indian & Development,
Journal July
of Public Health 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 962
1)
A B C NAAQS U.S. PP RI No.
3)

EPA 1997, 41/1999,

Parameter 2)
NAAQS U.S. 4)
Permenkes RI
Mean ± SD
EPA 2012, No. 1077/2011
PM10 (mg/m3)
Indoor (I) 0.215 ± 0.123 0.075 ± 0.246 0.229 ± 0.583 4)
0.70, 24 hours
1)
0.15, 24 hours,
Outdoor (O) 0.069 ± 0.527 0.094 ± 0.209 0.218 ± 0.152 3)
0.15, 24 hours
2)
0.05, 1 year
Conted…

I/O (p value) 3.116 (0.000) 0.798 (0.000) 1.050 (0.000)

Temperature (0C)
Indoor (I) 30.04 ± 0.99 30.08 ± 1.03 30.07 ± 0.61 4)
18-30
Outdoor (O) 43.98 ± 2.34 33.53 ± 0.35 36.4 ± 0.85
Humidity (% Rh)
Indoor (I) 69.85 ± 5.19 68.99 ± 5.13 65.72 ± 4.36 4)
40-60
Outdoor (O) 27.43 ± 5.36 52.73± 1.18 44.46 ± 3.36
Health Risk Assessment: The risk assessment was exceeded the standard value of 24-hour and annual
carried out on the exposure for three academic years to referring to NAAQS U.S. EPA 1997 and 2012, PP RI
the population of junior high school student in Depok. No. 41/1999, and Permenkes RI No. 1077/2011. It is
The respondents consisted of 157 males (44%) and 200 located in the city center and adjacent to a busy main
females (56%) with characteristics as shown in Table 2. highway. Traffic activity is one of the sources of indoor
One school day was 6 hours long not included additional
and outdoor particulate matters due to the burning
activities or lessons after school hours.
of fossil materials from motorized vehicles. Another
Table 2: Student Characteristic and Activity Pattern research on indoor PM10 reported that highway dust
was a major component of indoor PM10 and associated
Variabel Min-Max Mean ± SD with high levels of indoor PM 8. The I/O ratio at school
10
Age (years) 10.23 - 17.16 13.95 ± 0.82 C indicated that indoor PM might be sourced from
10
Body Weight (kg) Wb 22 - 89.5 47.90 ± 10.84 the classroom such as particles attached to students or
Frequency of resuspension of deposited particles6,20. In addition, the
exposure (day/ fE 188 - 218 215.41 ± 4.35 chemical component of PM10 might indicate the sources
year)
of pollutants and could be identified further6,8,21.
Duration of
Dt 1-3 1.60 ± 5.35
exposure (year) High indoor PM10 yet low outdoor PM10 was found at
Time of exposure School A. The level of indoor PM exceeded the
tE 6 10
(hour/day) guideline of 24-hour and annual referring to NAAQS
Inhalation rate U.S. EPA 1997 and 2012, PP No. 41/1999, and
R 15.7
(m3/day) Permenkes No. 1077/2011. 10
Low level of outdoor PM
might be caused by the rain that occurred a day before
The non-carcinogenic health risk of PM10 exposure measurement at School A. It was expected to dissolve
outdoor PM yet less affect on indoor.
to the students was HQ > 1 in School A and C, as shown This study did not record meteorological conditions
but
in Table 3. The exposure of PM10 was estimated to have several studies reported that meteorological conditions
health effects so risk management is needed by such as wind and rain can reduce the concentration of
setting
a safe threshold of 0.192 mg/m3 (for Wb = 47.9 kg) and PM22. By considering its environment characteristics, PM
0.142 mg/m3 (for Wb = 35.5 kg). might be sourced from traffic, not cemented school field,
or attached to students8,23. Similar to School C,
Table 3: Chronic Daily Intake dan Health Risk of PM10 indoor
PM10 might be sourced from the classroom and
School trapped
PM
A B C in due to deposited particles or inefficient room cleaning
10
Intake (CDI, mg/day) 0.011 0.004 0.011 and inadequate ventilation leading to the accumulation of
Health Risk (HQ) 1.118 0.390 1,191 indoor PM. Resulting in, School A had the highest I/O
ratio for PM10 . The mean percentage of V/C in School A
was not in accordance with Permenkes RI No.
1429/2006.
Discussion
Meanwhile, indoor PM10 in School B which located

10
PM10 Concentration: The concentration of indoor in the residential showed lower concentration. However,
and
outdoor PM were found to be highest in school C and the indoor PM were found to exceed the guideline
of
10
24-hour PM10 referring to Permenkes RI No. 1077/2011 for 3 years of exposure in School A and C
estimated
10
and annual referring PM to NAAQS U.S. EPA 1997. In the health risk to students (HQ> 1). Therefore,
10 we
10
residential areas, PM sourced from vehicles, recommend managing a safe threshold of PM at 0.142
10 PM
biomass
burning, cooking activities, and unpaved yards. The m/m3 as by conducting air quality monitoring, provision
concentration of indoor PM in School B was lower than of room air purification facilities in classrooms, and
10
outdoor PM and the I/O ratio was the least among three planning of school location to pollutant sources.
10
schools. This might indicate low contribution of indoor
sourced PM or good room cleanliness but might This research can be developed by monitoring
10 several
not
related the percentage of V/C. The mean percentage of quality parameters in the long run, simultaneously,
V/C at school B was not in accordance with Permenkes and considering the meteorology condition to obtain
RI No. 1429/2006. comprehensive air quality data. Health risks assessment
can be improved by analyzing the components of PM,
Health Risk Assessment: Health risks due to PM10 using advanced analytical methods, and involving
exposure to students were estimated in Schools A and C. epidemiological studies.
This study estimated health risk for junior high
school
students based on annual mean of PM10 (50 mg/m3) set Acknowledgment
by NAAQS U.S. EPA 1997. The U.S. EPA has
revised The author gratefully acknowledge the Universitas
the guideline to 150 mg/m3 for 24 hours because of Indonesia for providing financial support for this
insufficient evidence of long-term exposure on public research through Hibah Riset Penelitian Tugas Akhir
health. However, some studies reported association
of
long-term exposure of PM10 and respiratory problems in Year 2018 and generosity of various participants.
children i.e., study in Mexico finding an increase in PM10
Conflict of Interest: The authors declare that there is no
significantly correlated with decreased lung function of
conflict of interests.
children and a study in Utah showed a positive
correlation
with PM10 reduction and decreasing hospital visits, Ethical Clearance: This study was approved by the
asthma, and bronchitis in children16,24. In addition, WHO ethic board of Faculty of Public Health, Universitas
recommends annual PM10 50 mg/m3 and PM2.5 25 mg/m3 Indonesia (No.: 458/UN2.F10/PPM.00.02/2018).
expected to reduce the risk of premature death by 6%25.
The health risk of PM might be quantified based on its
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DOI Number: 10.5958/0976-5506.2019.01703.0

Analysis of Typhoid Fever Clinical Pathway Implementation in

the Era of National Health Insurance in Indonesia

Widia Puspa Hapsari1, Atik Nurwahyuni1

1
Department of Health Administration and Policy, Faculty of Public Health, Universitas Indonesia,
Depok, Indonesia

ABSTRACT
Starting in November 2016, pricing policy for private hospital in Indonesia was specifically set in a fixed
tariff called INA-CBGs (Indonesian Case Base Groups). PMI Hospital which was affected by INA-CBGs
regulation built Clinical Pathway for Typhoid fever in order to cope with the challenge. It admitted 705
cases in less than a year in 2016 yet it was claimed that the reimbursement for each case was still lower
than the hospital cost. Study aimed to explore variation of medical practices based on Clinical Pathway
considering INA-CBGs 2016 pricing policy. Cases included in the study were 156 cases with
homogenous severity level chosen from October 2016 to March 2017. Historical data was taken from
hospital information system including medical record and billing details. Data was processed using
ClinPath V.2.0 tools developed by Faculty of Public Health Universitas Indonesia resulting in distribution
of variation. Variation resulted in Length of Stay was (4.27 days) and it was expected to be 4-5 days in
clinical pathway while not all patients utilized the same procedure within one period of care. There were
also non-value added diagnosis such as Complete Urine (0.01) and Electrolyte test (0.01) included.
Consumption of antibiotic (0.28) which consisted of 25 different trade names from different structures
resulted in various tariff of services. Variation drives medical cost resulted in tariff increment. Typhidot test
can be taken into consideration and the use of later generation of antibiotics are recommended considering
affordability and availability.

Keywords: Clinical Pathway, Medical Practice, Compliance, Typhoid Fever,

Variation
Introduction offered by BPJS (third party payer) was quite lower than
the cost made by the hospital.
Shifting system from fee for services to Case Base
Groups had given new insight for hospitals to be more Typhoid fever frequently happened in Bogor area
(where PMI hospital is located). In 2016, there were
efficient in spending their resources without putting
18.797 cases of Typhoid fever in Bogor and it was
aside their service quality1. Started in 2016, tariff for
distributed among various age groups4. It was recorded
private hospital for each case group was set in fixed that Typhoid fever cases in PMI hospital alone was
amount and was prospectively reimbursed by BPJS 705 admissions in less than a year3. Those numbers
(Independent pooling organization for national health showed that PMI hospital had both the opportunity as
insurance)2. PMI (Indonesian Red Cross) Hospital is a well as the challenge to manage its resources in a more
type B private hospital with 264 beds as a referral efficient way. In order to answer the challenge, PMI
hospital for inpatient care in local area3. During the hospital has established their own Clinical Pathway for
enactment of INA-CBGs Typhoid fever. Length of Stay for homogenous cases of
Typhoid fever were found to be 1 up to 6 days. Studies in
2016 pricing policy, hospital claimed that
reimbursement several countries showed that prospective payment
system (e.g. INA-CBGs) would affect Length of Stay,
type of services and consequently the medical cost5–8.
Implementation of INA-CBGs pricing policy supported
Corresponding Author:
with clinical pathway was expected to reduce non-
Atik Nurwahyuni
value added activities yet variation still existed. Thus, a
Department of Health Administration and Policy, more in depth analysis needed to be conducted to
Faculty of Public Health, Universitas Indonesia, elaborate which medical practices induced more variation
Depok, Indonesia to the service.
Email: [email protected]
966 Indian Journal of Public Health Research
Indian & Development,
Journal July
of Public Health 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 966

Method doctor’s approvals. Hospitals provided patients with

their accommodation of choice. Fifty three patients
This study took place at PMI Hospital located
chose to utilize class I, 27 patients chose class II, 34
in Bogor, West Java. This study used quantitative
patients chose VIP class, and lastly 19 patients preferred
approach to identify variation in medical practices and
VVIP class (See Table 1). Various medical services
was elaborated using descriptive statistics. Distribution
were used in treating patients with Typhoid fever.
of patients’ characteristics included age, sex, payment
Doctor visits were given 4 times (once per day) in
methods (JKN/National Health Insurance, Private
clinical pathway while only 0.39 of the services was
Insurance, Out of Pocket), and inpatient accommodation
practically performed by the Internists during the stays.
(class I, II, III, VIP, VVIP). Data for identifying Length
Average tariff of doctor visits was IDR 94.739. The data
of Stay were also taken from the duration between
shows that average utilization of consultation was 0.02
admissions to the discharge date. Data taken from
and average tariff for each consultation was IDR 79,839.
medical record was then recapitulated and digitized
Complete blood test was utilized 0.06 times (IDR
by medical record unit. Another set of data were taken
78,537).
from billing unit, for example billing details. Medical
and medical supporting services details were then
classified as Laboratory, Consultation, Doctor Visits, Table 1: Characteristics of Patients with Typhoid
and Procedure. Drugs were also classified using ISO Fever
(Informasi Spesialite Obat) for its therapeutic functions.
Items Cases
Fragmented data were connected using registration
Number of Cases (N) 156
number. Data selection resulted in 156 homogenous
cases with the same severity level (without any LOS (Days)
complication and comorbidity). Data was processed ALOS 4.27
using a public domain software ClinPath V.2.0 built Minimum 3
by Universitas Indonesia. Variation showed in LOS, Maximum 6
Average utilization of medical and medical supporting
Age (Years of Age)
services, and various medical consumption of drugs,
and average tariff for services then be compared to Average 24
hospital clinical pathway. Minimum 1
Maximum 82
Results Sex (%)
Male 45.51
Since its initial implementation, Typhoid fever
clinical pathway has not been evaluated. According to Female 54.49
the hospital internal consensus, Length of Stay (LOS) Payment Methods (N)
for Typhoid fever was 4-5 days and patients were JKN 74
planned to be discharged with doctors’ approval. Several Private Insurance 19
medical activities e.g. anamnesis, physical assessment,
Out of Pocket 37
diagnostic examinations, procedures, monitoring up
Hospital Staff 1
to discharge planning were supposed to be conducted
within LOS. Other 25
Discharge Status (N)
Average Length of Stay for homogenous cases was
With Approval 151
4.27 days with maximum stays up to 6 days and the
least stays were 3 days. Vast majority of patients paid Against Advice 5
services using Indonesian National Health Insurance/ Type of Accommodation
JKN (74 patients), 37 patients paid out of pocket, I 53
and II 27
19 patients paid via Private Health Insurance, they were
III 34
mostly workers and were insured by the companies’
third party payers e.g Admedika, Inhealth, Antam, Sinar VIP 23
Mas, Sampoerna. Five patients were discharged against VVIP 19
advice and the rest of 151 patients were discharged with
Complete urine test (0.01) and Electrolyte (0.01) Table 3: Average Consumption of Drugs Based on
tests were also conducted and average tariff for both Clinical pathway
services were each IDR 45,969 and IDR 319,000.
Medical Procedures e.g. Crystalloid IVFD average Clinical Clinical
Drugs
Pathway Practice
utilization was 0.04 while it must be done every day (4
times during stays), each service was worth IDR During stays
161,333. Nursing care was given with average utilization Quinolone + -
of 0.39 (4 times in clinical pathway). Nursing care Cephalosporin + -
included monitoring body temperature, nutrition PPI + +
intake, and personal hygiene. The service average Discharge Planning
tariff was IDR Chloramphenicol Oral + -
56,669. Tariff for Injection was IDR 49,493 and was Cephalosporin Oral + -
given 0.37 times during 1 period of care (See Table 2). PPI + +
Note: + Drugs recommended by hospital CP or utilized
Table 2: Average Utilization in Medical and Medical in clinical practice, - not utilized in clinical practice
Supporting Services
Hospital Drugs used for discharge planning were consumed
Clinical Clinical
Items Tariff
Pathway Practice starting on the last day of stays up to consecutive
(IDR)
days after discharge (See Table 3). Variation included
Visits by Specialist 4 0.39 94,739
antibiotics classified not only in quinolone (with 4
Consultation - 0.02 79,839 variation in trade names) and cephalosporin (25 different
Diagnostic trade names), but also from other lines and generations.
Examination
Complete Blood Table 4: Average Consumption of Drugs
1 0.06 78,573
Test
Widal/tubex 1 - - Drugs Therapeutic Clinical Medical
IgM Salmonella - 0.02 251,304 Classification Pathway Practice
SGOT - 0.02 48,000 Adsorbents - 0.33
SGPT - 0.02 47,677 Analgesic - 1.11
Complete Urine Analgesic Opioid - 0.03
- 0.01 45,969 Anti-Dysrhythmia - 0.01
Test
Electrolyte (Na, K, Anti-Histamine - 0.74
- 0.01 319,000
Cl) Anti-Hypertensive - 0.05
Medical Procedure Anti-Inflammatory - 0.30
Crystalloid IVFD 4 0.04 161,333 Anti-Platelet - 0.01
Oxygen *4 - - Anti-Spasmodic - 0.07
Electrocardiogram - 0.01 57,955 Antibiotic - 0.72
Nursing Care 4 0.39 56,669 Antibiotic (Skin & respiratory
- 0.49
Injection - 0.37 49,493 Infection)
Note: (*) Not necessarily mandatory. Tariff was counted Antiemetic - 0.80
using 2016 value of money (1 USD=IDR 13,519) Antipyretic - 0.06
Antithyroid - 0.32
Recommended antibiotics in hospital clinical pathway
Bronchodilator - 0.19
were mostly broad spectrum (Quinolone and
Digestive system - 0.14
Cephalosporin) (see Table 3) although, these were not
Laxative - 0.01
used in medical practices. Hospital also suggested using
Proton Pump Inhibitor (PPI) and practically used was Probiotic - 0.53
Omeprazole with different types of brands (0.30). Vitamin - 0.06
Conted… detect excessive substances in blood excreted in the
urine and infection related to urinary tract infections14–16
Anti-Depressant - 0.13
Salmonella typhi can be detected through urine culture
Vasoconstrictor - 0.05
for its Vi antigen and be best detected using PCR
Adenoreceptor - 0.08
method without any bacteriological changes
Relaxant - 0.03 interference . Nonetheless, high tariff for PCR test
17,18

Diuretic - 0.02 was still one of the considerations.

Vasodilator - 0.03
Decongestant - 0.01 Mostly used quinolone was Levofloxacin 500 mg
(IDR 1,500) because it was more affordable than other
Anti-Diabetic - 0.01
quinolone such as Levofloxacin IV Fluids (IDR
Compounding Medicine - <0.01
105,600) or Lexa IV fluids 750 mg (IDR 422,400).
Several drugs were also given to the patients with Ciprofloxacin used by hospital had the lowest tariff
typhoid fever e.g. Adsorbent classified drugs (0.33 (IDR 867) known for more severe adverse effect
tablet). There were also two kinds of painkiller used including nausea, nerve damage, and further myasthenia
in practice, Analgesic (1.11) and Opioid Compound gravis . Clinical Pathway recommended patients with
19

(0.03). Anti-Hypertensive e.g. Amlodipine (0.05), Anti- Typhoid fever to be given antibiotic per day of stay.
Inflammatory such as Triamcolone and Dexamethasone However, average consumption of 25 different
(0,3 tablet), Anti-Platelet in the form of Clopidogrel Cephalosporin (antibiotics) varied. Average tariff also
(0.01), Anti-Spasmodic as in Otilonium Bromide and varied from IDR 1,573 up to IDR 369,930. Frequently
Hyoscine Butylbromide (0.07). Other therapeutic drugs consumed antibiotics was 1 gm of Ceftriaxone given via
were also consumed as shown (See Table 4). injection (IDR 18,700). Each gram of Ceftriaxone
injection can be used for both adult or pediatric patients9.
As study resulted that the youngest patient suffered
Discussion
from Typhoid fever was a 1-year-old and the oldest
Typhoid fever can be detected by using was a 82-year-old. Ceftriaxone is also more active
microbiological procedure, serological procedure against gram negative bacteria and less active against
and other examination e.g. PCR test9. PMI Hospital positive bacteria20. Thus, ceftriaxone was mostly used
suggested widal test for diagnosing Typhoid fever on the (average utilization 4.61) to treat patients with Typhoid
first day of patient’s admission. This test only results on rather than other Cephalosporin drugs. However,
moderate sensitivity and specificity and can only be done Ciprofloxacin (belongs to Fluoroquinolone) had higher
on day 6-12 for specific antibody O or H and might rate of Salmonella infection eradication than
show negative result up to 30.0% of proven culture10. Chloramphenicol (90% compared to 89%)21.
Typhidot IgM however has 75.0% of sensitivity and
Consumption of PPI drugs was not necessarily
60.7% of specificity which made it more accurate in
needed unless there were adverse effect e.g. intestinal
diagnosing Typhoid fever than widal test did11. Average
injury of a non-steroidal anti-inflammatory drugs
tariff for Typhidot IgM in PMI Hospital was IDR
(NSAIDs)20. On that account, average consumption of
251.304, higher than the tariff for Widal test in
PPI drugs was only 0.30. Other therapeutic drugs
hospitals in the nearby area, which were IDR 55.000 for
namely Adsorbent containing Loperamide HCL (0.33)
private hospital and IDR 52.000 for public regional
was used to control acute non-specific diarrhea
hospital12,13. Despite the higher tariff for Typhidot IgM
associated with inflammatory bowel disease which
test, hospital took the test accuracy into consideration.
often happens to patient with Typhoid. There were 3
Diagnosis tests out of hospital clinical pathway types of laxatives used which worked differently.
e.g. SGOT/ SGPT became ineffective because patients Dulcolax containing bisacodyl (average utilization 0.02)
with Typhoid fever subsequently experienced clinical works in stimulating mucosal sensory nerves,
sign in which their level of enzymes increased due to consequently increasing peristaltic contraction of
endotoxicity, immune mechanism, and the consumption colon20. Mycrolax cointaining Sucrose (average
of drugs . Complete urine test is commonly used to utilization 0.02) works in creating bulk and increasing
9

amount of water in the system, and Lactulax, a non-

absorbable sugar/disaccharide (0.01)
used to treat constipation by pulling water out into colon Source of Funding: Study was funded by Directorate
also to reduce ammonia in blood to treat liver disease20. of Research and Community Empowerment Universitas
Lactulax was the most expensive laxative (IDR 125,400) Indonesia (DRPM UI) through International Indexed
among the other two Mycrolax (IDR 24,063) and Publication and Students’ Thesis Grant (Hibah
Dulcolax (1,580). PITTA
2018) on 2180/UN2.R3.1/HKP.05.00/2018 agreement
Commonly used analgesic was paracetamol (7,42)
number.
with average tariff (IDR 205) per tablet. It was used
to reduce temperature which followed Salmonella Ethical Clearance: This research has already passed
infection. Anti-inflammatory was also used in 17 ethical clearance done by Faculty of Public Health
different trade names. The most consumed Anti- Universitas Indonesia Ethical Committee with reference
inflammatory was Triamcolone (0.78) which worked number 671/UNF.F10/PPM.00.02/2018.
by suppressing inflammation due to enteric infection.
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Program Jaminan Kesehatan.; 2014.
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DOI Number: 10.5958/0976-5506.2019.01704.2

Analysis of Primary Health-Care Resource Preparedness for

Implementation of Maternal HIV Screening in Indonesia’s
Urban Areas

MM.Puspitasari1, Purnawan Junadi2

1
Postgraduate of Public Health, 2Department of Health Policy and Administration, Faculty of Public
Health, University of Indonesia, Depok, Indonesia

ABSTRACT
The Indonesian goverment’s minimum service standard (MSS) indicator stipulates that 100% of pregnant
women in the country must undergo HIV checks. in 2017, however only 7% of pregnant women underwent
such checks. The same condition applies to Depok City, where in 2016 only 3.6% of pregnant women were
screened. Because 86.6% antenatal examinations are done within primary-care facilities, this study has to
analyzed the preparedness of primary health-care resources in the implementation of HIV screening for
pregnant women.The research used qualitative method with in-depth interview, FGD and document review.
The Study found that human resource workers trained in HIV programs were not available at every Public
Health Center (PHC) and private primary health-care (PPHC) had no such workers were trained on HIV.
Roughly half (17 of 35) of PHCs Primary health care capable of HIV screening for maternal. No PPHC
facilities especially inpendent midwife practice had such capabilities The number of reagents was found to
be inadequate at the PHCs, and no reagents at all were found at prprivate care facilities. Counselling media
was found to be lacking at both types of primary care facilities. Conclusion the implementation of HIV
screening in primary health care facilities is not yet ready according to the MSS. Regulations that require
PPHC facilities to be capable of HIV screening and government support for the availability of resources
(especially training and reagents) are require for the achievement of the MSS.

Keywords: HIV screening, minimum service standards, urban areas,

Indonesia
Introduction Indonesian goverment has thus established a minimum
service standard (MSS) that recognize pregnant women
HIV screening for pregnant women is an important
as a high risk population for contracting HIV. Under
strategy for the prevention of mother-to-child
the MSS, 100% of pregnant women should under go
transmission of HIV and is mandatory in areas with
standardized HIV testing including screening7,8.
widespread and concentrated HIV epidemic status1.
Pregnant women in particular should be screened In terms of coverage of pregnant women screened
because more than 90% of pediatric HIV cases are occur for HIV in Indonesia only 570,424 (7%) of pregnant
through vertical infection2,3,4. Globally, the numbers of women were screened during from antenatal visits
HIV-infected women continue to increase.The same which were conducted on a total 5,355,710 pregnant
situation applies to Indonesia, where 2,573 women had women . The same condition applies to Depok City,
9

HIV in 2015 and by 2016 that numbered had increased an urban area, where the coverage of HIV testing for
to 15,151 women (36% of total HIV cases)5,6. The pregnant women in 2016 was only 1,839 pregnant
women(3.98%) from coverage of K1(first visit) antenatal
visit of 46,201
and K4 (4th visit) of 43,92410,11. These figures indicates
Corresponding Author: a missed opportunity, since HIV-positive pregnant
MM.Puspitasari women are likely unaware of their status, despite having
Postgraduate of Public Health, Faculty of Public Health, visited health services. Because of the large numbers
University of Indonesia, Depok, Indonesia of pregnant women in Indonesia, the need for HIV
Email: [email protected] screening is considerable.
972 Indian Journal of Public Health Research
Indian & Development,
Journal July
of Public Health 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 972

A 2016 data survey of the national health indicator Trained personnel is not yet available in all PHC
states that 86.6% antenatal examination performed Among 35 PHCs, only 30 PHC have counselors
at primary care consisting of Public Health Centers (includings doctors, nurses and midwives), ten have
(PHCs) and their related networks, private clinics and
trained laboratory analysts and nine PHCs have
independent practice midwives. Specifically, 40.2% of
these exams were carried out by independent practice specialized recording and reporting (RR) personnel.
midwives and 82.4% of the antenatal health workforce Because of the low number of workers executing (RR)
consisted by midwives12. This condition shows that personnel, the RR process is mostly done by counselors
primary health care facilities are still the main service in who obtain on- the -job training from the Health Office.
the provision of antenatal examinations. The low numbers of trained health personnel, the
heavy workloads of these personnel and the process of
The inclusion of HIV screening for pregnant women
in MSS indicator of HIV health care service and transferring trained personnel who does not match the
antenatal care providers mostly done in primary needs of the program have affected the poor coverage
health care as well as thedemand for such facilities of pregnant women to be screened for HIV and have
is higher than the supply which add to the Indonesian also become an obstacle to the availability of human
government’s obligation to allocate necessary resources in the PHCs. As one informant noted,
resources to support the implementation of screening
-----only a few human resources are trained,
programs. Researchers thus should analyze the
preparedness of primary healthcare resources in the and they also have other duties, so if these
implementation of maternal HIV screening in Indonesia. workers aren’t available then, the HIV
screening for pregnant women gets
Method postponed--- (KPKM-1)
The study used a qualitative method, with in-depth
In addition, human resources workers who are
interviews, focus group discussion with semi structured
interviews and document review. A total of 43 trained in private primary health-care (PPHC) facilities
informants participated in the study including policy- esspecially independet midwife practice, are not yet
makers, activity implementers and beneficiaries. The available. This condition has occured because of to the
research was conducted from November 2017 to January lack of specific training for private service workers even
2018. through 82.4% of antenatal examination conducted by
midwives and 40,2% are done in independent practice
Results
midwives, only about 27.1% of such examinations are
Human Resources: The human resources required for the done in PHCs12.
implementation of HIV screening are include health-care
workers who have competencies in accordance with their Facilities: Facilities for the implementation of HIV
profession and have been trained in HIV/AIDS programs 7. screening include health-care facilities, reagents and
media counseling.
PHCs, the primary-care of the government, have a
fewer number of trained HIV/AIDS workers than the Only 17 PHCs were found to be capable of
total number of health personnel available, as shown in providing
table 1 as follows:
comprehensive HIV screening to pregnant women in
Table 1: Trained health-care personnel on HIV in 2017. Even though trained human resources workers
PHCs in Depok City 2017 were distributed in 30 PHCs, this situation may have
arisen because reagents and human resources who are
Personnel Type Total Trained % capable of performing laboratory sample examination
Doctors 134 26 19.4 were only available at 17 PHCs.
Nurses 146 12 8.21
Midwives 182 28 15.3 These 17 PHCs thar were able to perform HIV
screening faced several obstacles only 13 PHCs that
Laboratory analysts 36 10 27.8
had trained analysts, HIV screening services were only
Recording and Reporting
9 offerd on limited days and waiting times were too long.
staff (RR)
The limited service hours and long waiting times made
Source: P3M section, 2017, processed data
pregnant women reluctant to be referred to PHCs for
HIV screening. As one informant noted,
---- Pregnant women whoare checked for the skills of health workers in providing counseling
HIV here are often lazy about being about HIV infection and give workers the ability to
referred to PHC for VCT (voluntary handle medical care effectively15. The lack of trained
counseling abd testing) because it’s far health personnel and health worker’s heavy workloads,
away, waiting times are long,they might be both affect the utilization of VCT services16. Thus,
too lazy tostand in line and they.re only increasing the numbers of health workers who are
available in the morning while they’re engaged in this field will also increase the number of
working--- “(BPM-1) pregnant women who undergo HIV screening.
Research indicates that the existence of trained health
PPHC facilities capable of HIV screening for
workers,esspecially doctors, who are able to provide
pregnant women do not yet exist for various reasons: the
counseling,influences affect pregnant women’s
goverment’s socialization of service is mot yet, trained
willingness to undergo HIV screening 171819.
personnel are not yet available and the government is
still focused on the availability of services at the PHCs. The National Health Indicator’s 2016 data survey
found that 84% of personnel who provided antenatal
The supply of reagents is essential for the care were midwives and 40.2% of these independent
implementation of HIV screening for pregnant women. practice midwives only 27.1% of such examinations
for PHC is obtained from The central and regional were performed in PHCs12. This finding indicates
governments determine the need for reagents for PHCs that increased coverage of pregnant women who
based on the planning needs proposed by PHCs through undergo HIV screening will require the involvement
The Health Office. But the goverment’s provision of of health personnel in both public and private sectors
reagents remains focused on the needs of PHCs, so the and midwives should be the priority target for such
number of reagents the government provides has not training. Cooperation with professional organizations
matched the estimates of total pregnant women because in socializing programs and training will be required
only 27.1% of pregnant women have had their antenatal in order to increase the active participation of private
visits at the PHCs 12. One constraint among several is healthcare personnels.
that the reagents PHC receive are often approaching
their expiration datebecause of delays in the delivery of In terms of facilities, the main factors to affect the
reagents from the central government as well as implementation are the lack of PPHC facilities that
technical constraints in the process of procuring of can conduct comprehensive HIV screening and the
reagents at the central and regional levels. limited capacity of PHCs. research suggests that the
unavailability of both human resources and facilities and
Another important factor in the process of long waiting times at service sites are obstacles to HIV
disseminating information about HIV screening for screening during pregnancy 202122.
pregnant women is the availability of counseling media
The absence of PPHC facilities that are capable of
at both PHCs and PPHC facilities is still lack where
screening pregnant women for HIV strongly affects the
special counseling media on the prevention of mother-
coverage of screening because it is difficult to reach all
to-child HIV transmission is generally unavailable.
pregnant women. For example PHCs are provide
only
Discussion 27.1% of services, while private health care provide
the remainder. 40.5% of antenatal visits are done by
Both human resources and facilities, are important
independent practice midwives. PPHC facilities must
in the implementation of the goverment’s policy,
be involved, including in the provision of reagents for
the limitations of both will hamper will hamper the
private services. The integration of HIV services with
successfull implementation13,14.
health-care services in general, both in the public and
The low numbers of trained health personnel in private sectors, is needed to achieve the objectives of
PHCs and in the private sector, especially the midwives, the implementation, such integration is is a necessary for
have affected the implementation of the program. The more effective and efficient service .
2324

aim of Education and training for health personnel is to Counseling media on HIV screening for pregnant
improve compliance in implementation and supplement women is still lacking both in government and
PPHC
facilities. The media that can be used for information, of Universitas Indonesia based on Letter No. 565/UN2.
education, and communication include Mother and F10/PPM.00.02/2017 dated November 6, 2017.
Child Health (MCH) book and social media because
every pregnant woman is required to have an MCH Source of Funding: This study was sponsorred by
book. The use of social media as a bridge to disseminate Universitas Indonesia through Indexed International
information about HIV screening for pregnant women Publication for Student’s Final Project Funding
can increase public knowledge of the importance of
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DOI Number: 10.5958/0976-5506.2019.01705.4

Getting Married to a Suspected Bisexual Man: A Silent Mode

of HIV transmission among Married Women in Indonesia

Najmah1,2, Sharyn Graham Davies1, Sari Andajani1

1
Auckland University of Technology, Auckland, New Zealand; 2Sriwijaya University, South Sumatra
Indonesia

ABSTRACT
A married woman is susceptible to contract HIV from her husband if he practices unsafe sex, especially
with other men. Unsafe sexual practice (heterosexual and homosexual sex) are the major factors of
significant increase of HIV in Indonesia for the last decade. The aim of this study is to reveal one woman’s
story about living with HIV. She contracted from her husband after he was unsafe sex with men.
Feminist Participatory Action Research was conducted in 2017 with HIV positive women, health workers
from public and private organisations. Qualitative research methods were used in line with purposive
sampling method and thematic analysis.
Men who have sex with men (MSM) may contract HIV through unsafe homosexual practices. Women need
to be informed about the risk factors of contracting HIV and Prevention of Mother to Child Transmission-
PMTCT of HIV services. In addition, compulsory antenatal HIV testing is urgently needed to early diagnosis
of HIV among pregnant women and a non-discriminatory practice of comprehensive Prevention of Mother-
to-Child Transmission of HIV (PMTCT) services is urgently required to prevent HIV transmission for
infants.

Keywords: MSM, bisexual man, a married woman, mother to child transmission, PMTCT service,
Indonesia
Introduction Method
In the past decade, four out of every 10 people Research Paradigm and Methodology: Feminism
diagnosed with HIV in Indonesia were women and the is chosen as our epistemological stance and Feminist
highest number of late stage of HIV (AIDS) suffers Participatory Action Research (FPAR) as the research
are married women or housewife (1). Married women methodology. Feminism includes a philosophical belief
are considered a neglected group in HIV prevention in system that addresses who can be the real knower
Indonesia (2, 3). As a consequence of the lack of focus on of women’s problem and solution and care for the
married women, they have become a ‘silent majority’ relationships between the female researcher and the
of new HIV-positive cases (1). In Indonesia, the majority research participants (8, 9). Feminist research also seeks to
women living with HIV find out their HIV status after contribute to women’s empowerment (10), as women have
their husband or children die, or after they themselves the potential means to contribute to the development
become ill (4-6). Unsafe sexual practices are now the main
of collective consciousness, through their active
cause of increases in HIV rates in Indonesia (1, 7). There
participation, shared knowledge, and collaboration in the
is a little knowledge about lived stories of a married
research itself (9, 11). Within FPAR, three main
woman who is more likely to contract HIV from their
dimensions of social transformation allow the necessary
husband who experiences to have unsafe sex practice
place and space to reposition gender, race and class, “to
with other men in Indonesia context.
excavate indigenous cultural knowledge and generate
Correspondence Author: voices”; and “to deploy intersectionality as an analytic
Sari Andajani tool for transformation” (12), pp 331. In addition, focusing
Auckland University of Technology, gender and diversity of women’s experience and voices
Auckland, New Zealand are an integral part of this FPAR in challenging a
Email: [email protected] patriarchal culture (13).
977 Indian Journal of Public Health Research
Indian & Development,
Journal July
of Public Health 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 977

Participants: This study is a part of the whole requirement for the surgery. Following the delivery
study of
of FPAR that was conducted in 2017 with a group
of
18 HIV-positive women, a group of 26 health workers,
and a group of nine NGO workers. The voices of these
groups were travelled visually to the final group of 12
stakeholders related to HIV in Palembang. Purposive
sampling was undertaken to recruit participants in
Palembang (capital city of South Sumatra) Indonesia.

Data Collection and Analysis

The methods used included informal or “go-along”

or informal interviews (14), focus group discussions and
participant observations over four months in Palembang.
In addition, participatory visual methods were used
during the Focus Group Discussions and interviews.
These methods allowed for HIV-positive women and
other groups to express their thoughts through visual
representations, such as drawing, collages and mind-
mapping (15-18). The data collection was conducted by the
first author, who was born and raised in Indonesia and
was fluent in the local dialect of Palembang. Thematic
analysis and reflective analysis were then conducted.(13, 19-
22)
.

Result

Preventing Mother-to-child Transmission: Mira

recalled the time when she started to feel that the
labour was coming. Her pain was excruciating, and the
contraction came closer to each other. Psychologically,
she felt very worried that her baby would be infected
with HIV during delivery. Mira, accompanied by
Kuyung then rushed to the emergency unit at a public
hospital. At the admission, she reported her HIV status:
“I am positive HIV, I needed a Caesarean Operation”.
The admission nurse at that time, however, did not
believe her and Mira insisted for the nurse to contact the
Voluntary, Counselling and Testing (VCT) centre where
she and her husband had been treated for HIV. The
nurse contacted the VCT centre and got confirmation of
Mira’ status. She was scheduled to have the caesarean.

During the waiting time, or at about 6 pm, Mira felt

her contractions intensified. Yet the nurses kept telling
her that she would be fine. Two hours later, at about 8
pm, Mira had delivered her baby naturally. She felt very
tired and shaken and after her delivery Mira realised
she did not have any meals or drinks since 2 pm as a
978 Indian Journal of Public Health Research
Indian & Development,
Journal July
of Public Health 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 978
Toleh, Mira’s second child, both the mother and baby
were transferred to the maternity ward and shared her
in-patient room with other female patients.

Vulnerability and discriminatory practice: During

her recovery process, Mira recalled some incidents
when she received blame, discriminatory treatments
from the nurses. For example, one of the nurses had
asked her “you knew that you were HIV-positive, why
did you decide to be pregnant and deliver your baby?”.
Other nurses would give signs to her peers of her HIV
status, mocking on Mira, while Mira was present in the
room. At the same time, Mira felt hopeless. She was
angry and disappointed with the treatment she received,
but there was not much she could do then hoping for
some ‘empathy’ from the nurses, midwives or doctors
at the hospital. After a few months of her recovery, she
asked about a family planning of Intra Uterine Devices
in the same hospital, however, she got rejection after she
disclosed her HIV status. Fortunately, after 18 months of
being treated with a preventative HIV medication, her
son, was declared HIV free.

HIV vulnerability: deception in marriage: During her

second pregnancy in 2015, Mira recalled going to the
community health centre to have a check on her vaginal
rashes and itchiness. The test results confirmed she had
syphilis and HIV. Her CD4 count of 350 cells/mm3.
Feeling shocked, Mira told Kuyung and demanded for
Kuyung to take a blood test. Kuyung was diagnosed HIV
with a CD4 count of 450 cells/mm3. Mira or Kuyung
was likely to be infected with HIV about four years ago
year (23). Both Mira and Kuyung were referred to the
VCT clinic for Antiretroviral treatment and accessed
PMTCT services to prevent HIV to Toleh.

Mira was not sure who whether she or her husband

acquired the HIV or syphilis first by saying “I did not
know, who got it first, he [Kuyung] is a man”. At some
point, Mira was also suspicious she might have acquired
HIV from an unsterile syringe used by one of the staff
at a family planning clinic. A year prior to her problem,
Kuyung had told her about having genital itch and there
were reddish-brown sores around his genital area.

HIV vulnerability: norms on heterosexual marriage:

To gain further understandings on MSM in Palembang,
the first author decided to seek further information and
meeting peer support workers and outreach HIV workers
who had been working with bisexual and gay
communities
and health workers in VCT centres. Learning from lived may contribute the significant increase of HIV among
stories of the insiders, the authors became aware of life MSM in Indonesia (1, 7, 30). The risk of HIV transmission
of MSM in Palembang that may differ from MSM from through anal sex is 18 times higher than vaginal sex
other countries, like New Zealand. MSM, either bisexual without use of condom (31), however, the rate of condom
or gay man, may contract to HIV through unsafe sex use, which is effective for preventing HIV and other
practice, have relationship with a female partner and not STIs, is very low amongst married couples (7, 32).
all of MSM may disclose their sexual orientation and
HIV status to their male and female partners. Preventing HIV among men having sex with men
is still complex as their sexual practices are perceived
as immoral and sinful. Consequently, this may actively
Discussion
prevent them from seeking HIV tests or disclosing their
In Mira and Kuyung’s marriage, there was a sexual orientation to their wives or other sexual partners
(28, 29, 33)
complex interplay of deception, stigma around . As a result, unsafe heterosexual and homosexual
homosexuality, heterosexual morality and HIV stigma in relationship, a long period of asymptomatic HIV and
health setting. Kuyung might have engaged in deception within marriage may result in ‘silent’ HIV
homosexual sex prior to him marrying Mira, yet there epidemic among Indonesian women. Another threat of
was no knowledge whether Kuyung continued his sexual this complexity of HIV transmission is a new mutation
practice with men after his marriage with Mira. Kuyung of HIV virus or recombinant strain of HIV is more likely
also had never disclosed his sexual orientation to Mira to be occurred in Indonesia, like a recent study case
nor had he ever seek to do an HIV test although he was among MSM in China (34).
infected Syphilis one year prior to Mira.
Conclusion
This spouse was eager to seek Caesarian Section
and disclose their HIV status, however they were failed This paper indicates that sexual transmission of HIV
to get one. The risk of Mother To Child Transmission occurs among married women and men in a number
can be reduced from up to 50 % without accessing any of ways, including unsafe sexual practice between
treatments to less than 5% by women accessing effective a married woman with a husband who has sex with
treatment during pregnancy, safe labour practice, and
men. Consequently, heterosexual married women have
formula milk-feeding (or breastfeeding with certain rules)
become a ‘silent majority’ of new HIV-positive cases.
through PMTCT services (24, 25). Caesarian section is seen
The notion of the shame, sinful, a hidden life-style about
main alternative for safe delivery for pregnant women
being a bisexual or gay man means that people do not
living with HIV in limitted CD4 and viral load test (25).
talk about HIV and homosexual sex within a marriage.
We suggest in Mira and Kuyung’s life were embedded to
Unfortunately, there is limited HIV screening of
their
‘perception of susceptibility’ (26). Mira, and most Muslim pregnant women meaning women unknowingly pass
women, are taught that being a mother is prestigious HIV to their babies. Consequently, women need to be
and a high status job in Islam as per the famous hadith: informed about the web of risk factors of contracting
“Paradise lies at the feet of the mother” (27). HIV within a deception and unsafe sex practice of men
having sex with men with their heterosexual partners.
HIV among MSM may bridge HIV transmission Women should be empowered to make responsible
to married women as this present study also highlights decisions in their own right to reduce contracting HIV
being a bisexual and gay men was a considered as a from their partner and transmitting HIV to their babies.
lifestyle choice by participants. Being bisexual and In order to reduce of the risk of mothers transmitting
gay man is perceived as ‘abnormal’ and ‘sinful’ within HIV to their children and to enhance their early access
the discourse of heterosexual morality (28, 29), hence, to PMTCT services, these services need to be aware and
bisexual and gay men in Indonesia may give up and address these gender discriminatory factors in their
decided to getting married to adhere to heterosexual
training and policies.
normality in Indonesia (29). To reduce social risk on their
gayness, MSM generally did not open about their sexual Ethical Clearance: AUTE on 7 March 2017 (Reference
orientation in public space, including to their female No. 17/22), Sriwijaya University (Reference No. 39/
partners (29). Unfortunately, unsafe homosexual practices keprsmhfkunsri/2017) on 15 March 2017
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DOI Number: 10.5958/0976-5506.2019.01706.6

mHealth Development for Village Midwives to Improve the

Performance of the Maternal Health Program in the Babakan
Madang Sub-District, Bogor, Indonesia

Rico Kurniawan1, Kemal N. Siregar1, Nimas S. Martiana1, Indriana K. Wardhani1

1
Department of Biostatistics and Population Study, Faculty of Public Health, Universitas Indonesia

ABSTRACT
Maternal mortality rate is still high in Indonesia, supported by a decrease in K1 coverage. This incident
often involves pregnant women who have not received services from the village midwife. An electronic
application has been developed to improve the midwives’ performance; however, since their workload is
extremely high, many field activities, outreach, and mapping of pregnant women have not been well carried
out. Village midwives will be equipped with an electronic application (mHealth) that will also be used
by health cadres so that all pregnant women in the village can be mapped. With a better data collection
mechanism for pregnant women, a map could be produced in all villages and the data could produce more
accurate program objectives, such as identifying pregnant women in high-risk condition and preparing a
better work plan. Moreover, maternal health performance can also be known immediately in real time by
stakeholders, especially by the head of the sub-district and the public health center.

Keywords: maternal health, midwife, mobile health

Introduction direct (such as bleeding) and indirect causes (such as
maternal nutritional status, poor maternal knowledge,
Maternal mortality rate (MMR) is an important
and the mothers’ ages, either too old or too young).
indicator for improving maternal health status. The
Late decision making, referring, and case handling are
number of mothers who died due to complications from
often factors that are found in obstetric complications
pregnancy and childbirth decreased from 532,000 in
cases3. Information regarding the targeted number of
1990 to 303,000 in 2015. More than 800 women die
pregnant women in a work area is still lacking. Some
every day due to pregnancy and childbirth
pregnant women were not recorded because they were
complications1. Efforts to reduce maternal mortality are
not accessed by health services.
still a priority in Indonesian health development. The
causes of maternal deaths in several countries were As the spearhead of services in the work area,
72.5% direct and 23.5% indirect2. In 2015, Bogor had a midwives have heavy workloads, which means that
maternal mortality rate of 69, consisting of 2 pregnant individual outreach is often not carried out optimally.
women’s deaths, 17 childbirth deaths, and 31 postnatal Health information technology (HIT) has the potential
death; three deaths in the Babakan Madang sub-district to improve individual health, quality, costs, and greater
contributed to the city’s number. Maternal mortality in care. Research conducted in assessments that provide
Bogor had several health information found that 92% of the latest
health
HIT articles reached positive conclusions. It also found
Corresponding Author: smaller benefits and services, and many more were
Rico Kurniawan initial users4.
Department of Biostatistics and Population Study,
Faculty of Public Health, Data quality and documentation are needed to
Universitas Indonesia, A Building 2nd Floor, provide safe and appropriate services for the mother.
Kampus Baru UI Depok 16424, Indonesia For a long time, paper was used to record and report
Email: [email protected] patient health and epidemiological data. However, with
982 Indian Journal of Public Health Research
Indian & Development,
Journal July
of Public Health 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 982

the advent of technology, paper is slowly being replaced Implementation: The system is implemented using
by electronic media5. mHealth is a part of eHealth that a research operational approach. Implementation is
extensively covers electronic and digital health carried out by identifying problems related to lack
processes through telephones, computers, and the of system management control, which is caused by
internet. In Kenya, mHealth was using to send text training resource issues, as well as an incomplete data
messages about malaria case management to rural and information from midwives. Work with partners
clinicians. In Tanzania, information was exchanged via to introduce this new implementation strategy into the
SMS between pregnant women and health facilities, health system and facilitate implementation, as well as
which increased skilled birth attendance to 60% an evaluation, as needed.
compared to 47% in a control group6. Ethiopia has used
In Babakan Madang’s community service program,
mHealth in the MCH field, especially in referral cases.
target users, such as midwives, cadres, health centers,
Health workers are receptive to mHealth because it eases and village officials, are trained to use an mHealth
their work, which has made many health workers application. Each user is given a form relating to health
outside of MCH request mHealth development in their data that needs to be recorded. The form consists of the
fields, such as immunization, family planning, and Mother Data Collection Forms and reporting forms for
other disease services7.mHealth has attracted attention cadres at integrated health pots (Posyandu) level, the
as a means of supporting material, newborn, and child Maternal Care Form for midwives, and the Reporting
health in developing countries, and research to assess the Form for Vital Registration for village officials.
impacts of health interventions is increasing8. Recorded data is then reported by sending data via
mHealth application to the server. Reports can be
To improve the maternal health program in Babakan
monitored by midwives, community health centers, and
Madang, mHealth was developed to assist the recording village officials via the mHealth website.
and reporting of maternal health activities. This tool is
used by midwives and the community (cadres) in data
Results
collection for pregnant women; recording and reporting
maternal health services is carried out to improve the The maternal health program is currently still
midwives’ performance. Midwives and workers in documented and reported manually by midwives.
health centers can monitor maternal health and Midwives work independently from the data collection
anticipate risks that will arise through the application. In process for pregnant women, history, examination,
addition, maternal health performance can also be recording of examination results, early detection of risk
known immediately in real time by stakeholders, factors, and reporting data. The number of duties that
especially by the head of sub district and the head of the a midwife has means that she cannot guarantee that all
health center. her work will be done optimally, so it is normal if the
maternal health program’s coverage is still low.
Method Input Requirements Analysis: The identified input
System Development: The methodology used in the components include health service facilities, health
resources, funding, and stakeholders and organizations’
development of this application is rapid application
support. In this case, health service facilities are health
development (RAD), which combines various
centers where data are reported (database), and health
structured techniques with prototyping and joint
resources are midwives in five villages and health cadres
application development techniques to accelerate the
that assist midwives during the data collection process
system development process. There are three stages
with the inclusion criteria of having a smartphone
in RAD: requirement planning, design workshop, and
(Android). Funding is the incurred cost during mobile
implementation. Requirement planning involves a health use, namely the loss of data and hosting packages.
needs analysis that explores problems and determines Stakeholders and organizations’ support come from
solutions. The design workshop explains how the health centers and related health offices that encourage
business process flows in the use of the mobile health system development, and facilities and infrastructure
system. Implementation refers to the introduction of the that assists midwives and cadres in increasing maternal
socialization system that has been formed. This mHealth health programs’ coverage.
model uses the Open Data Kit platform.
Process Requirement Analysis: In the process of filling Mobile health development will empower health
the mother’s card in as primary data on maternal health cadres to assist midwives in carrying out data collection.
services, the midwife must initial data collection of The cadre will record pregnant women by visiting
pregnant women to get first visit (K1) coverage
pregnant women’s homes thoroughly and using mobile
according to the target. After the initial data collection,
the midwife checks the mothers who come to health care phone-based applications. Therefore, when the mother is
facilities on a regular basis. From the results of routine registered, she can go to the health care facility to conduct
examinations, the midwife can detect any risk factors that an examination, which be the midwife’s responsibility.
could endanger the mother and fetus’s health so that they The examination results will be documented using web-
can be prevented or anticipated early. The process series based applications or a mobile phone; this will ease the
was carried out independently by the midwife until the work, so the midwife’s performance is expected to be
data was reported to the public health center regularly more optimal and maternal health services’ coverage can
every month. increase.

Figure 1: Workflow design of mHealth

Output Requirement Analysis: As previously explained, the recorded inspection results are reported every month
as local monitoring for the maternal program report. Midwives must recapitulate manually, which some have called
a burden that takes a lot of time and feels less efficient. For this reason, the development of mobile health
applications aims to facilitate the maternal data recording and reporting process by making it web-based or done on
a mobile phone. In addition, the application can facilitate reading data by displaying a dashboard that can be
adjusted according to the level of the reader (Head of Public Health Center, Coordinator Midwife and Health
Office). Based on needs from users, we developed several forms to facilitate both midwives and cadres regarding
recording and reporting activities. For midwife, we created the form for recording and reporting on maternal
health. As for cadre users, we developed seven forms to facilitate the recording and reporting activities at integrated
health post (Posyandu).
Figure 2: Monitoring tools

Figure 3: Direct data visualization

Discussion officials can immediately recapitulate the results and
take the next step, resulting in more time.
Research conducted on eight choices made online
in Indonesia shows that mobile phone use in health
services bring positivity. The perceived benefits reported Conclusion
are: (i) ease of contact between patients, midwives, and
mHealth was implemented in Babakan Madang
supervisors; (ii) increased time efficiency due to the
to improve the performance of midwives in the public
ability to coordinate visits; and (iii) if complications
health center. The work process was carried out using
occur, assistance is only one call away9. At present,
an electronic-based mHealth application (web and
almost all communities, both rural and urban, use
android). Initial data collection was assisted by cadres to
smartphones. Moreover, health workers and midwives
reach all pregnant women in the Puskesmas work area.
have used hand phones in patient referral systems. As
This makes midwife work more effective because master
an example of using mHealth in the field of maternal
health, India uses a Mother and Child Tracking System data is available as a reference in providing services, so
that registers pregnant women and children using cell the midwives can immediately conduct anamnesis and
phones so that they get scheduled services. Uganda uses examination. Thus, the performance of midwives can
the UNICEF Birth Registration System with rapid SMS increase because the process of digitizing the maternal
to maintain an electronic database center so that data health program can ease their work.
are less confusing and more efficient10. According to the
With the mHealth application, the system of
study about mHealth intervention’s role in maternal and
recording maternal health programs becomes more
child health service delivery, findings from a
efficient and effective because it implements a paperless
randomized controlled field trial in rural Ethiopia
system in real-time, so that the resulting data becomes
showed that short message service-based mobile
telephone intervention could indeed improve the more accurate. In addition, coverage of pregnant women
effectiveness of frontline health worker, primarily in who are recorded is expected to increase because the
improving access to antenatal care, delivery services, data collection process is assisted by cadres. Mobile
and postnatal care. The number of ANC visits and phone solutions may save the lives of women and their
percentage of deliveries attended by health workers newborns, and may contribute to the achievement of
improved, and also facilitated the work process of Millennium Development Goals 4 and 5; therefore, they
frontline health workers11. should be considered by maternal and child health policy
makers in developing countries16. mHealth interventions
This research is in accordance with previous studies targeted at pregnant women can be an effective solution
relating to the use of electronic devices to help improve to increase service utilization to improve maternal
the performance and quality of workers, especially in the and neonatal outcomes. Integration of mHealth into
health sector, such as the Indian health service system
the healthcare system can pave the way to improved
and the Mosoriot Record System in Kenya, which states
decision making on how best to implement mHealth
that enabling electronic devices can increase employee
interventions17.
productivity and satisfaction, save time, and provide
better quality data12.Activities carried out in several Source of Funding: This is a community engagement
developing countries gave the same results. The level of program that fully supported by Directorate of Research
poverty and a decrease in the quality of life of the and Community Engagement (DRPM) Universitas
community13. mHealth has also been developed as a Indonesia.
surveillance tool for research conducted in Sub-Saharan
Africa14. Conflict of Interest: The authors declare that there
is
There is some positive evidence for the effect no conflict of interests regarding this article or research.
on mHealth interventions on outcomes, such as
ANC attendance, skilled attendance at birth, and oral Ethical Clearance: This research has obtained ethical
contraception utilization15. It is evident that mHealth permission from the ethics commission in the Public
use can increase effectiveness and security for village Health Faculty Universitas Indonesia register number
officials and equipment. Since cadres can immediately 659/UN2.F10/PPM.00.02/2018.
send collected data to the server, the midwife and
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Milen A. Improvement of maternal health services eview. PLoS One. 2016;11(5):e0154664.
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DOI Number: 10.5958/0976-5506.2019.01707.8

The Influence of Dental Health Education on the Gingival

Health of Students at STIKES Muhammadiyah Palembang

Dientyah Nur Anggina1, Resy Asmalia1

1
Department of Publich Health, Medical Faculty, University of Muhammadiyah Palembang,
South Sumatera, Indonesia

ABSTRACT
Students often suffer from gingivitis due to stress and lack of awareness of the need to maintain good
oral hygiene. One strategy for improving the behaviors to maintain good oral hygiene is Dental Health
Education (DHE). This study aimed to analyze the influence of DHE on the gingival health of students
in STIKES Muhammadiyah Palembang. This study was quasi-experimental with a pre-test and post-test
design. Sampling was accomplished with the total sampling method, which resulted in the inclusion of 36
students in the first level of midwifery at STIKES Muhammadiyah Palembang. This study used a
simulation method of tooth brushing and the study instruments consisted of a gingival examination and
knowledge questionnaire. The measurements from pre-test to post-test showed that the students’
knowledge of oral hygiene improved and their severity of gingivitis decreased, according to their gingival
index scores. The results of the Wilcoxon test analysis showed p<0.05, meaning that there were
significant differences in students’ knowledge and gingival health before and after participating in DHE.
Thus, the study results revealed that DHE had a significant influence on gingival health.

Keywords: Dental Health Education; gingival health; students.

Introduction Data from the Indonesian Dentists Association
show that the prevalence of gingivitis worldwide is
People who are classified as “students” range in age
from late adolescence (18-21 years) to early adulthood 75%-90%. In Indonesia, gingivitis is the second most
(22-24 years) and are currently registered and studying frequently occuring oral disease, affecting 95.8% of the
at a College. As students transition from their late teens population3. Gingivitis is an inflammation of the gingiva
to early adulthood, they are at an age at which they that does not result in the attachment loss of clinical
should be able to adapt to various demands and new gingiva, the main cause of which is the accumulation
environments1. In terms of their growth and of plaque in the cervical area of teeth and their
development, students often have oral hygiene problems, surroundings. Gingivitis can be prevented by controlling
especially of the gingiva. Oral hygiene is a very
plaque mechanically, such as by brushing the teeth, and
important means of preventing these problems,
chemically, by using toothpaste as well as mouthwash
particularly because some problems develop specifically
that contains antimicrobial agents4. According to
due to poor oral hygiene. If oral hygiene is not properly
maintained, it can affect the health of the entire body Dumitreschu et al. (2010)5, the gingiva-related problem
because the teeth and mouth are an integral part of the often experienced by students is gingivitis which can be
body’s system2. caused by psychological factors, such as stress, which
commonly occurs as part of college life. Stress can
induce an increased accumulation of plaque, which can,
Corresponding Author:
Dientyah Nur Anggina in turn, increase the risk of gingivitis in college students.
Department of Publich Health, Medical Faculty, In addition, gingivitis in students can also be caused by
University of Muhammadiyah Palembang, a lack of awareness of the need to maintain good oral
South Sumatera, Indonesia hygiene.
Email: [email protected]
988 Indian Journal of Public Health Research
Indian & Development,
Journal July
of Public Health 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 988

Strategies are being developed to improve the 34 and 46), students with gingivitis, and students with
behaviors that lead to good oral hygiene, particularly as willingness to participate in this study. Excluded from
it relates to the gingiva, including the simulation-based this study were students who were smokers,
approach known as Dental Health Education (DHE). menstruating or pregnant, wearing an orthodontic
DHE is a learning process aimed at individuals and appliance, or had a systemic disease and had used an
community groups to help people achieve the highest
antibiotic during the month before this study. After
possible level of oral hygiene. To succesfully change
inclusion and exclusion criteria were met, a total of 36
behaviors, the aim of DHE can best be realized by
students comprised the sample that participant in this
choosing the right teaching method6. The advantage
study.
of the simulation method used in this study is that it
can provide experience, encourage decision-making, The instruments used in this study took the form of
and share the value of good oral hygiene. It can be
a gingival examination and a knowledge questionnaire.
used to individuals, groups and entired communities.
The examination of gingival health used the using
The simulation activities can be easily understood by
gingival index (GI) assessment according to Loe and
learners so that their application of the skill taught yields
Sillness ; the first upper right molar (16), the first upper
positive7.
left incisor (21), the first upper left premolar (24), the
STIKES Muhammadiyah Palembang was chosen first lower left molar (46), the first lower right incisor
as a research location because it currently offers no (31), and the first lower right premolar (34). Probing was
research on gingival health and the lack of counseling done at the gingival sulcus of each tooth, with each tooth
about oral hygiene has resulted in students having calculated on four sides (i.e., mesial, distal, facial and
insufficient knowledge of how to maintain good oral lingual) and divided by 24. The examination results
hygiene, especially as it relates to gingival health. The were categorized as 0 (healthy), 0.1-1.0 (mild
preliminary survey data of this study showed that 70%
gingivitis), 1.1-
of 90 college students in the first level midwifery have
2.0 (moderate gingivitis), or 2.1-3.0 (severe gingivitis).
a low level of oral hygiene. This study aimed to analyze
the influence of Dental Health Education (DHE) on the The questionnaire was used to determine the
gingival health of students at STIKES Muhammadiyah student’s level of knowledge with 10 sentences
Palembang. regarding oral hygiene and was scored according to
three categories; “high” if the score was between
Method 76% and
This study was quasi-experimental study and used a 100%, “adequate” if the score was 56% and 75%, and
pre-test and post-test design. Pre-test and post-test were “low” if the score was lower than 56%8. Other tools and
accomplished through an examination of gingival health materials used in this study were a periodontal probe,
and an assessment of student’s knowledge before and mouth mirror, nierbekken, mask, hand scoen, alcohol
after participating in DHE. The assessment consisted 70%, and a dental model.
of students filling out the questionnaire that was score
according to whether answers were correct (score = 1) or Data were collected in several stages; 1) the
incorrect (score = 0). DHE was performed by counseling recording of each respondent’s identity, 2) before the
using a tooth brushing simulation by modified Stillman intervention (DHE) took place, respondents gave their
method. informed consent, 3) during the pre-test, when the
gingival health was examined using the gingival index
This study was conducted at STIKES and when the respondents filled out the
Muhammadiyah Palembang, and total sampling was questionnaire,
used to select subjects who met the inclusion criteria; 4) when the intervention (DHE) was given to the
students in the first level of midwifery studies at respondents, including the toothbrush simulation with
STIKES Muhammadiyah Palembang, students who had the modified Stillman method, and 5) one week after
their own teeth (the element of teeth were 16, 21, 24, 31, DHE, the respondents returned for the post-test which
included another gingival health examination and
questionnaire. Data were analyzed using the Wilcoxon
989 Indian Journal of Public Health Research
Indian & Development,
Journal July
of Public Health 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 989
test to determine the influence of dental health education
(DHE) on student’s gingival health
Results The Wilcoxon test was used to determine whether
DHE with the toothbrush simulation had the effect of
Table 1: The oral hygiene knowledge levels of the improving student’s knowledge of oral hygiene and the
respondents result obtained was p value = 0.000 (p value < 0.05).
This result indicates that there was a significant
Before DHE After DHE
Categories difference in the levels of knowledge before and after
n % n %
DHE. A similar result was obtained as it relates to the
High 16 44.4 34 94.4 gingival health examination. Based on the Wilcoxon
Adequate 18 50 2 5.56 test, the result obtained was p value = 0.002 (p value <
Low 2 5.56 0 0 0.05), which means that there was a significant
Total 36 100 36 100 difference in the Gingival Index before and after DHE.
Notes: n = number of sample, % = percentage Thus, it can be concluded that DHE using the
toothbrush simulation significantly influenced gingival
Based on Table 1, before DHE, only 44.4% of health by improving the student’s level of knowledge
the students had a high level of knowledge about oral and decreasing their severity of gingivitis (Table 3).
hygiene. This indicated that 55.56% students with only
an adequate or low level of knowledge did not know Discussion
about the importance of maintaining oral hygiene,
especially their gingival health, which increased their Knowledge can be improved with information,
risk of gingivitis2. After DHE, 94.4% of students showed which can, in turn effect changes in behavior.
a high level of knowledge. Knowledgeable people typically have greater awareness
and behave according to what they know9. Oral hygiene
Table 2: Result of the gingival health examination of information can be provided by Dental Health Education
respondents (DHE), which aims to achieves high levels of oral
hygiene6.
Categories Before DHE After DHE According to Notoatmodjo10, this increase in
N % N % knowledge likely took place because the learning
Healthy 0 0 0 0 process provided new information that substituted for
Mild Gingivitis 26 72.2 36 100 previous knowledge or represented an improvement
Moderate Gingivitis 10 27.8 0 0 over existing knowledge. If someone has a specific sense
Severe Gingivitis 0 0 0 0 on object or stimulus after information is given, either
TOTAL 36 100 36 100 through the sense of hearing, sight, smell, taste or touch,
the possibility of improving knowledge grows stronger.
The knowledge provided about gingival health in this
Notes: n = number of sample, % = percentage
study included the impact of not maintaining good oral
The results of the gingival health examination using hygiene along with a recommendation of an effective
the Loe and Sillness Gingival Index (GI) can be seen in method and frequency of toothbrush.
Table 2, which shows that, 27.8% of the students had
According to Loe and Sillness (1963)11, the
moderate gingivitis before DHE. As was seen in this symptoms of moderate gingivitis include gingiva
study, after DHE, the severity of gingivitis had already enlargement, erythema, and bleeding when probing.
decrease. All of the students had only mild gingivitis after Students are vulnerable to gingivitis because of college-
the study and not a single student had even moderate related stress and a lack of awareness of the need to
gingivitis. maintain gingival health5. Actually, most of the students
Variable Result Probability (p health
value) in this study were already familiar with an appropriate
Table 3: The influence of DHE on gingival frequency of toothbrush, but their severity of gingivitis
Level of Pre-test
was probably because they did not fully understand how
knowledge Post-test
to brush their teeth correctly.
Pre-test 0.000
Gingival Index 0.002
Post-test In this study, students simply practiced better
oral
hygiene during this study which can be known after the
activities had been done continuously. Therefore, DHE more easily absorb and remember the information14.
with simulation can improve awareness and knowledge The students who participated in this study, as a young
that can change behaviors and, in turn, improve oral people aged 17-22 years have already begun to make
hygiene, especially as it relates to the gingiva. Stillman independent decisions about their health, adapt to the
method was used as a simulation method in this study new information about their environment, and form and
because it was a highly recommended, simple and adopt behaviors that affect their health1. As such, this
efficient toothbrush method that can applied in all study was in line with a study conducted by Haryani
parts of the mouth. This method also can give gingival et al., which sought to demonstrate that dental health
massage and expected to clean debris in interproximal promotion can improve student’s oral hygiene. After
area and gingival sulcus11. the students in that study were given dental health
The decrease in the Gingival Index scores after one information using an interactive lecture method, the
week post DHE indicated a decrease in the severity of results showed increased oral hygiene index scores15.
student’s gingivitis and an improvement in their gingival
health, perhaps because the students were motivated Conclusion
to follow the toothbrush instructions and maintain
The results of this study showed that Dental Health
good oral hygiene. This result contrasts with the study
Education (DHE) significantly influenced improvement
conducted by Herliana et al., in which there were no
in the gingival health. The simulation method used in
changes in Gingival Index scores after study respondents
this study could increased student’s knowledge and
received counseling through video. These different
decreased the severity of their gingivitis, so the students
results suggest that if an individual has the necessary
could easily understand and remember how to correctly
knowledge but does not apply it every day to maintain
brush their teeth.
good oral hygiene, it can have poor implications for oral
hygiene particularly gingival health12. Motivation is the Conflict of Interest: The authors declare that there is no
force that can encourage a person to act. Motivation is conflict of interests.
also important stimulus in the health education process
because it is needed to change existing behaviors and Source of Funding: This study is self-funded.
maintain new and improved behaviors13. Motivation Ethical Clearance: This study was approved by the
was demonstrated by the students in this study in Ethical Committee of Medical Faculty, University of
their maintenance of gingival health and their positive Muhammadiyah Palembang, Indonesia, the approval
response to the knowledge they gained during DHE. number is 049/EC/UBHKI/FK-UMP/X/2018
The use of the simulation method in DHE is one of
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DOI Number: 10.5958/0976-5506.2019.01708.X

A Smart Nutrition Management System and Nutrition Related

Diseases in Humans

Kardokh H. Kaka Bra1, Eko Supriyanto1,2,3

1
School of Biomedical Engineering and Health Sciences, Faculty of Engineering, 2Advanced Diagnostics
and Progressive Human Care Research Group, 3IJN-UTM Cardiovascular Engineering Centre,
Universiti Teknologi Malaysia, Johor, Malaysia

ABSTRACT
The rapid rate of urbanization and world population increase has given rise to new challenges. Increasingly
more nutrition- and metabolic-related conditions are appearing as a result of poor nutritional management
and lifestyle choices. Clearly, without food management, a person could suffer enormous drawbacks in his
or her private and social life. The objective of this project is to help people eat smarter and more mindfully,
manage their body conditions, and further improve their relationship with food, in order to facilitate the
early diagnosis of certain diseases (e.g., cardiovascular diseases) and to improve the recovery as well as
prognosis of these diseases. A system, method, and computer program for integrated, personalized nutrition
management is proposed in this study. The nutrition management system features a user data calculation
processing unit that calculates the required nutrient quantity for a person based on the person’s data. It also
calculates the excess or deficiency of nutrients of the person based on the required nutrient amount and
nutrient evaluation outcome data of the person, including a meal information search engine user interface
that searches for the food data based on input from the user. The system was used by a small group of 20
university students and staffs who, overall, found the experience to be useful and functional with comments
to improve the search engine user interface. The results of analysis were fetched fast and accurately.
Therefore, the system can be used not only by the general population, but also by dietitians and nutritionists
to accurately manage and personalize the nutritional wellness of the society.

Keywords: Nutrion, Management System, Computer-based, Smart System, Disease Management, Early
Diagnoosis
Introduction and buffers within the remarkable, fluid environment of
metabolism. States of dietary deficiency or excess could
Nutrients supply energy and are the building blocks
take place when a person’s food consumption does
of numerous materials, which are important for the
not match his or her necessity for optimum wellbeing.
growth and livelihood of each human being.
Therefore, a balance between nutrient consumption and
Macronutrients contribute the entire required energy.
nutrient necessities must be maintained 1,2,3.
However, in the end, the energy that macronutrients
yield will be used to ensure muscular tissues and organs Resolution making involves selecting various
of the body function properly. The release of energy for courses of motion out of a given number of courses to
production, motion, and different capabilities is achieve a purpose or objective4. Resolution making is
dependent on the micronutrients, which operate as a prestigious scientific, social, and financial endeavor.
coenzymes, co-catalyst, Hence, a choice-making scenario entails partial,
incomplete, or inexact data. A decision support system
(DSS) is a responsive computer-based system, which
Corresponding Author: assists resolution makers to make the most of
Eko Supriyanto information and models to unravel unstructured
School of Biomedical Engineering and Health Sciences, issues5,6,7. In some resolution conditions, assistance
Faculty of Engineering, Universiti Teknologi Malaysia, supplied in the form of information and model
Johor, Malaysia administration alone is probably not enough8. An
Email: [email protected] expert system (ES) presents further
993 Indian Journal of Public Health Research
Indian Journal&ofDevelopment,
Public HealthJuly 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 993

assistance that could substitute human experience via the end report against the nutrients obtained from daily
supplying the required data; nevertheless, a number of foods through algorithms to find out whether there is an
different smart services can also be utilized to assist excess or deficiency in the nutrients. When a user inputs
decision-making that requires experience9,10,11. ES is an personal data, the data is sent to the back-end of the
influential technique that helps decision-making and can system and management unit, where it will be processed
be applied for a wide range of issues12,13,14. and then recorded. In the case of calculating daily
calorie requirements or
Therefore, in this project, we establish a nutrition macronutrients/micronutrients, the input data is
management system to deal with inexact, and overall processed using mathematical formulas to output
unhealthy eating habits. individualized results for each user. This program
manipulates the food, menu, and meal and search
Method database. The user can then choose a recommended
general and therapeutic menu using this system based on
A system, method, and computer program for
his or her preference and lifestyle (Figs.1 and 2).
integrated, personalized nutrition management is
proposed in this study, starting with the crafting of a In the case of the meal analyzer, the management
graphical user interface for the system using Filemaker® unit searches for special codes in the database to find
Pro 16 Advanced, which is an SQL-based, cross- a corresponding food nutrition component table. It then
platform relational database management system that sends the corresponding food nutrition component table
facilitates the implementation of a database engine along to the front-end user interface and compares these results
with a graphical user interface utilizing the same to the recommended dietary requirements of calories
software. The nutrition management system in this and essential nutrients in the form of a report (Fig. 5).
study features a user data calculation processing unit
that calculates the required nutrient quantity for a The user can also take advantage of the
person (the user) based on the user data and calculates cardiovascular risk assessment portals to determine the
whether the person has an excess or deficiency of potential possibility of developing coronary heart
nutrients based on the required nutrient amount and diseases in the next 10 years of his or her life as well as
nutrient evaluation outcome of the user data. The system receive customized lifestyle and dietary
also provides a meal information search engine user recommendations based on the results of the analysis.
interface that searches for food data based on input from The minimal design of the database’s graphical user
the user, and a meal information calculation processing interface displays the daily ingestion amounts for a
unit that calculates the nutrient quantity obtained from a variety of nutritions, sends a report that states
meal based on the meal analyzer data. Furthermore, it whether the nutrition of the user is insufficient or in
also provides food information based on the nutrient excess, and provides possible diseases and conditions
quantity and shows whether the person has an excess or corresponding to the nutrition insufficiency or excess.
deficiency of nutrients. The system is designed in such a
way that allows the user to input information such as Several predictive equations can be used to
age, gender, weight, height, level of activity, and calculate the basal metabolic rate of the user such as the
whether or not the user smokes, into different fields, Harris-Benedict, Mifflin-St Joer and WHO/FAU/UNU
each with a drop-down menu whenever convenient, to equations. In our database, for the estimation of daily
assist in the filling up of data. The user could also calorie requirement, the predictive equation for resting
choose weight goals such as “lose weight”, “maintain energy expenditure (REE) based on the Mifflin-St Jeor
weight”, or “gain weight”, which are implemented in a study was utilized because it is the most reliable and
separate field. After filling out these fields, the accurate according to the literature14,15,16. This equation
“recommended daily energy requirement” and the is provided below:
“energy to achieve goal” is also calculated at the back-
REE (males) = 10 × Weight (kg) + 6.25 × Height
end of the system and presented to the user, along with
the recommended daily intake for other macro- and (cm) – 5 × Age (y) + 5
micronutrients, each personalized according to the data REE (females) = 10 × Weight (kg) + 6.25 × Height
obtained from the user. It is the quantity of these (cm) - 5× Age (y) – 161
calculated nutrients that the meal analyzer will output as
In a study in 2014, to evaluate the efficiency presence of special conditions of the user (e.g.,
of the BMR formulas, the BMR of overweight and cardiovascular disease) (Fig. 4).
normal-weight people was measured using indirect
calorimetry (IC), and then the outcomes observed from
the predictive formulas were assessed to evaluate the
variations presented between estimated values and those
calculated by IC. In both cases, the Mifflin-St. Jeor
formulas were the most accurate, with a variation
of
-9.1% when compared to IC in obese individuals
and
0.9% variation compared to normal-weight individuals.
The research reported the Mifflin-St. Jeor equations as Figure 1: Flowchart of the principal parts of the
the most accurate equation for estimating BMR since database (LEL: Low Energy Level, MEL: Medium
it is the only equation that allows the valid prediction Energy Level, HEL: High Energy Level)
of BMR in obese individuals. The study did not advise
using the equations of FAO/WHO/UNU, Harris and
Benedict, Schofield, and Henry and Rees for predicting
BMR in these populations, because these formulas tend
to exaggerate energy demands. However, these formulas
could still produce satisfactory results in predicting
the BMR of normal-weight individuals. Nonetheless,
they advised that the BMR of overweight patients be
measured more carefully and cautiously so as the most
convenient course of action pertaining to the foundation
of physical activity level and eating pattern of this group
is accurately represented16. Figure 2: Welcome screen layout for the graphical
user interface database
To calculate the recommended daily calorie intake,
after taking into account physical activity level (PAL)
(Fig. 3), the guidelines below are referred to:
z 1.200 = sedentary (little or no exercise)
z 1.375 = light activity (light exercise/sports, 1–3
days/week)
z 1.550 = moderate activity (moderate exercise/
sports, 3–5 days/week)
z 1.725 = very active (hard exercise/sports, 6–7 days
a week) Figure 3: The screen for calculating user daily
calorie requirements
z 1.900 = extra active (very hard exercise/sports and
physical job)

Daily Calorie Requirement = REE×PAL

The user is able to choose from a selection of

different eating styles including the Popular style,
Vegetarian style, Mediterranean style, and Malaysian
style. Each style encompasses a variety of food
components such as vegetables, grains and cereals, meat
and poultry, fruits, oils, and legumes. The food
components of each style are quantified precisely and
Figure 4: The screen for the recommended
personalized according to the daily calorie needs and the
eating styles of the user based on the nutrition
management system
system and a diet management application that could
enable nutrition management and acknowledgement of
food-associated conditions. Within the diet management
system, in line with the application example described
above, the consumer information could embody private
data, where the private data could include attribute
information relating to at the very least one of gender,
weight, age, or physical activity of the individual. Then,
the user data calculation processing unit could calculate
the required nutrient quantity of the person primarily
based on at the very least one of gender, weight, age, or
Figure 5: The meal analyzer search engine user physical activity of the person. Therefore, the system
interface can be used by not only the general population, but also
by dietitians and nutritionists who have the
Results responsibility of creating menus for clients, and
specialists in the field of food and nutrition. It can
In this study, a nutrition management system was
also be a useful tool for nutrition education and
developed, which utilizes a user information calculation
nutrition counseling, as it can help establish a really
processing unit that calculates the required nutrient
comprehensive connection between food and body.
amount of the user based on user information and
calculates the nutrient excess or deficiency information Conclusion
of the user based on the required nutrient amount. It
then outputs the nutrient analysis result information for Daily energy needs is the most important nutritional
the user. The system was used by a small group of 20 determinant because energy should be provided
university students and staffs, who overall found the regularly to meet the requirements of the human body to
experience to be useful and functional with comments to survive. Every individual has to be aware of his or her
improve the search engine user interface. energy status so that he or she could strike a balance
between energy intake and consumption and make an
Therefore, the system can be used by not only the educated decision regarding his or her eating habits. The
general population, but also by dietitians and purpose of a sufficient and well-organized diet is to
nutritionists, who have the responsibility of creating prevent calorie and nutrient excess or deficiencies.
menus for clients, as well as specialists in the field of Nowadays, there is increased understanding of the vital
food and nutrition. It can also be a useful tool for roles that diet has in the initiation or prevention of
nutrition education and nutrition counseling, as it can certain diseases, such as cardiovascular diseases, stroke,
help establish a really comprehensive connection cancer, and diabetes mellitus. Insufficient energy intake
between food and body. will restrict the potential of populations in many
developing and third- world countries, while excess
Discussion energy and food intakes are increasingly giving way
to very high occurrences of obesity and its
After using the system, the users were asked about accompanying complications across all socio-economic
their overall experience in using the different parts of groups in both developing and developed countries. This
the system and to provide feedback about the idea study is an attempt to provide a practical and easy-to-use
of integrating cardiovascular risk estimation into the tool for comprehensively understanding healthcare and
developed system. Their reactions were mostly positive. decision-making concepts.
Several were impressed with the implementation of the
food composition database and daily meal analyzer. Acknowledgment
However, they suggested improvements to the search
The authors would like to acknowledge all
engine graphical user interface so that it would have
individuals who have contributed to this study, including
a more practical feel. One strong point to improve the
Universiti Teknologi Malaysia and PT Karya Indonesia
features of this service was to supply a diet management
Cerdas for their support in the preparation of this paper.
Conflict of Interest: The authors declare that there is no 9. Vergéres G. Nutrigenomics - Linking food to
conflict of interests. human metabolism. Trends in Food Science and
Technology. 2013;31:6-12.
Source of Funding: This study is funded by PT Karya
Indonesia Cerdas, Indonesia, through a research grant 10. Hong S-M, Kim G. Web Expert System for
(R.J130000.7651.4C223). Nutrition Counseling and Menu Management. J
Community Nutrition. 2005;7(2).
Ethical Clearance: This study does not require ethical
clearance. 11. Marti A, Goyenechea E, Martinez JA.
Nutrigenetics: a tool to provide personalized
nutritional therapy to the obese. J Nutrigenet
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DOI Number: 10.5958/0976-5506.2019.01709.1

Dominant Hypertension Factors of Adolescents in West Java,

Indonesia

Mujahidil Aslam1, Trini Sudiarti1, Ratu Ayu Dewi Sartika1, Engkus Kusdinar Achmad1
1
Department of Community Nutrition, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia

ABSTRACT
Adolescents are susceptible to degenerative diseases such as hypertension. The hypertension prevalence of
the adolescents in West Java, Indonesia is 10.5%, which exceeds the national prevalence of 8.7%. This
cross- sectional study was conducted in 2018 in West Java, Indonesia, and involved 152 students selected
using a simple random sampling technique. The data was analyzed using chi-squared and logistic
regression tests, and the results revealed that 11.8% of the students exhibited hypertension. Moreover, the
significantly related factors included the sex, body mass index/age, and sleeping duration, while the sex of
the students most dominantly influenced the hypertension rate (p=0.021, odds ratio=8.9). Based on these
results, adolescents in Indonesia should undergo regular blood pressure checks, and they should be
encouraged to eat more balanced diets, while reducing fatty foods, in order to reduce their risks of high
blood pressure and obesity.

Keywords: age, body mass index, blood pressure, sleeping duration,

sex
Introduction Based on the National Health and Nutrition Examination
Survey (NHANES) data, the 2016–2017 hypertension
According to the Centers for Disease Control and
prevalence among adults was 29% (30.2% of men
Prevention, adolescents are in the development stage
and 27.7% of women). The prevalence rate increased
of the transition from childhood to adulthood at 10–
changes until 2016. Additionally, the 2016 NHANES
19 years of age. As described by the United Nations
data showed that there was a blood pressure increase
International Children’s Emergency Fund’s definitions
in children and adolescents (8–17 years old) in the
of prehypertension and hypertension, teenagers fall
US5. According to the Basic Health Research data from
into two categories: early adolescence (10 –14 years
2013, the hypertension prevalence in Indonesia (≥ 18
old) and late teens (15–19 years old) 1. In adolescents,
years old) was 25.8%; it was 29.4% in the West Java
hypertension is defined as repeated systolic and diastolic
Province and 27.6% in the Bogor Regency6. The Basic
blood pressures above the 95thpercentile2.
Health Research data from 2007 reported hypertension
Hypertension is a blood vessel disorder from 1999 prevalence of Indonesian adolescents 15–24 years
to old was 8.7%, while the prevalence in West Java
2010; however, there were no permanent that interferes was
with the oxygen supply and nutrients carried by the 10.5%. These rates show the hypertension prevalence
blood to the tissues that require them. This disease often of individuals ≥18 years old and 15–24 years old in the
arises without any symptoms, so it is considered to be a West Java Province were higher than the national level7.
“silent killer”3. The prevalence of hypertension in Some of the factors contributing to the high
adolescents is 4%, and an increase in a single blood hypertension prevalence of adolescents cannot be
pressure measurement indicates a 4% to 17% changed, such as genetics, sex, race, and age. However,
susceptibility4. some risk factors can be changed, including obesity, lack
of exercise or physical activity, stress, smoking, alcohol
consumption, potassium, calcium, and a diet high in fat
Corresponding Author: and sodium8.
Trini Sudiarti
Method
Department of Community Nutrition,
Faculty of Public Health, This cross-sectional study was conducted at Health
Universitas Indonesia, Depok, Indonesia Vocational School located in Bogor, West Java,
Email: [email protected]
Indonesia. The research began in April–May 2018,
with a total
998 Indian Journal of Public Health Research
Indian Journal&ofDevelopment,
Public HealthJuly 2019, Vol.10,
Research No. 7
& Development, July 2019, Vol.10, No. 7 998

152 students which chosen by simple random sampling was because women have higher prevalence of healthy
technique as respondents based on the Lemeshow living behaviors than men, such as healthy eating
difference in proportions hypothesis test. The data habits and avoiding smoking and alcohol consumption.
collected included direct interview using a questionnaire, Additionally, male adolescents have higher
subject characteristics, physical activity level, sleep hypertension risk because they accumulate more
duration, and stress. The subject characteristics (the visceral and intra- abdominal fat.
sex and family history of hypertension) were obtained
directly using a questionnaire. The anthropometric data Table 1: Univariate Analysis
(height and body weight) were used to measure the Percentage
Variable Total
(%)
nutritional status by dividing the BMI (kg/m2) by the
age (years). The weight was obtained by having the Yes 18 11.8
Hypertension
subjects step on to a scale (increments of 0.1 kg), and No 134 88.2
the height was measured using a Microtoise (increments Male 7 4.6
Sex
of 0.1 cm). The nutritional intake data (amounts of Female 145 95.4
sodium, potassium, calcium, fat, fruits, vegetables, and Yes 44 28.9
Genetic
water consumed) was obtained from direct interviews No 108 71.1
using a 2 x 24-hour dietary recall method (weekday and Overweight 30 19.7
weekend). The questionnaire and interview formats were BMI/A
Normal 122 80.3
based directly on the Physical Activity Questionnaire
Over 76 50
for Adolescents (PAQ-A) and the Perceived Stress Natrium intake
Adequate 76 50
Scale. Each subject’s blood pressure was obtained using
Defisit 76 50
mercury sphygmomanometer. The physical activity Pottasium intake
levels were obtained using questionnaires and interviews Adequate 76 50
based on the PAQ-A. Defisit 76 50
Calsium intake
Adequate 76 50
Results
Over 76 50
Fat intake
Table 1 shows 11.8% of the students exhibited Adequate 76 50
hypertension 95.4% were females; 28.9% had genetic Fruit Defisit 114 75
(family) histories of hypertension, and 19.7% of the consumption Adequate 38 25
students were overweight. The nutrient intakes were as Vegetable Defisit 99 65.1
follows: 50% had high sodium intakes, 50% had low consumption Adequate 53 34.9
potassium and calcium intakes. Another results 50%
Water Defisit 75 49.3
had high fat intakes,75% had low fruit intakes, 65.1%
consumption Adequate 77 50.7
had low vegetable intakes, and 49.35% had low water
intakes. Furthermore, 37.5% of the students exhibited Sufficient 95 62.5
Physical activity
low physical activity levels, 3.9% smoked, 31.6% had Less 57 37.5
low sleep durations, and 88.2% exhibited stress. Yes 6 3.9
Smoking
No 146 96.1
The bivariate statistical test results are shown in Less 48 31.6
Table 2. The results of the odds ratio testing (OR=6.50, Sleep duration
Sifficient 104 68.4
95%[CI] 1.32-32.85) showed that the male students had
Stress 134 88.2
a 6.50 times higher risk of hypertension compared to Stress
the female students. This corresponds with the research No Stress 18 11.8
conducted in Brazil which showed the gender exhibited a The results also showed a higher BMI/A proportion
significant relationship with hypertension; the percentage in the hypertension cases (OR=5.38, 95% [CI] 1.91-
of males (22%) with hypertension was greater than the 15.14). These results correspond to study which
percentage of females (9.7%)9. A study also reported the described a significant relationship between the BMI/A
males had higher risk of hypertension than females10. It and hypertension11. A study showed the adolescents with
higher BMI/A ratio had 12.3 times chance of developing dysfunction. Teenagers with overweight experience an
hypertension12. A study in India also showed a significant increase in sympathetic nervous system activity, which
relationship between the BMI and hypertension13. causes increases the heart rate and blood pressure. The
However, a study in Brazil showed there was no insulin resistance occurs due to obesity inhibits glucose
significant relationship between BMI/A and absorption and affects the sodium resistance, causes the
hypertension14. heart rate and blood pressure. The insulin resistance
which occurs due to obesity inhibits glucose absorption
Obesity is one of factors associated with
and affects the sodium resistance, which causes increase
hypertension in adolescents, and related the activation of
in the blood pressure15.
sympathetic nervous system, insulin resistance,
and vascular
Table 2: Bivariate Analysis
Hypertension
Hypertension No hypertension
Variable OR 95% CI p value
(n = 18) (n = 134)
n % n %
Male 3 42.9 4 57.1 6.5
Sex 0.036*
Female 15 10.3 130 89.7 1.32 – 31.85
Yes 6 13.6 38 86.4 1.26
Genetic 0.873
No 12 11.1 98 88.9 0.442 – .3.608
Overweight 9 30 21 70 5.38
BMI/A 0.002*
Normal 9 7.4 113 92.6 1.91 – 15.14
Over 9 11.8 67 88.2 1
Natrium intake 1
Adequate 9 11.8 67 88.2 0.37 – 2.67
Defisite 11 14.5 65 85.5 1.66
Pottasium intake 0.451
Adequate 7 9.20 69 90.9 0.61– 4.56
Defisite 12 15.8 64 84.2 2.18
Calsium intake 0.209
Adequate 6 7.9 70 92.1 0.77– 6.17
Lebih 8 10.5 68 89.5 0.77
Fat intake 0.802
Cukup 10 13.2 66 86.8 0.28 – 2.08
Defisite 16 14 98 86 2.93
Fruit consumption 0.244
Adequate 2 5.3 36 94.7 0.64 – 13.42
Vegetable Defisite 8 8.1 91 91.9 0.37
0.089
consumption Adequate 10 18.9 43 81.1 0.13 – 1.02
Defisit 9 12 66 88 1.03
Water consumption 1
Adequate 9 11.7 68 88.3 0.38 – 2.75
Less 9 15.8 48 84.2 1.79
Physical activity 0.365
Sufficient 9 9.5 48 90.5 0.66 – 4.81
Yes 3 50 3 50 8.73
Smoking 0.022*
No 15 10.3 131 89.7 1.61 – 47.19
Less 11 22.9 37 77.1 4.12
Sleeping duration 0.009*
Sufficient 7 6.7 97 93.3 1.48 – 11.43
Stress 15 11.2 119 88.8 0.63
Stress 0.45
No Stres 3 16.7 15 83.3 0.16 – 2.43
This study showed a difference in the proportion one-time risk of developing high blood pressure, and
of smoking between those individuals with and without this was a significant relationship16. Contrarily, a study
hypertension (OR=8.73, 95% [CI] 1.61-47.79). It means showed no significant relationship between smoking
the students who smoked exhibited hypertension 8.73 and the hypertension incidence17. Smoking is one of the
times more often. These results are similar to a study causes of hypertension. This is because the chemicals
which showed that the adolescents who smoked had contained in tobacco can damage the inner walls of
a
the arteries, making them more susceptible to plaque results of a study showed low potassium intake had a
build-up (atherosclerosis). Additionally, the nicotine significant relationship with hypertension20. Finally,
in cigarettes can stimulate the sympathetic nervous the present study showed no significant relationship
system, which increases the heart rate and constricts the between the calcium intake level and hypertension.
blood vessels. Moreover, the carbon dioxide released by This corresponds to the results of study conducted
cigarettes can replace the oxygen in the blood, forcing among high school students in Semarang, which also
the heart to work harder to meet the oxygen demands showed significant results between the calcium intake
of the body18. The results of this study also showed level and hypertension22. However, a study conducted
that differences in the sleep duration were related to among adolescents in Semarang showed the calcium
hypertension (OR=4.12, 95% [CI] 1.48-11.43). This intake level did have a significant relationship with
means that those students with a lower sleep duration blood pressure23. The present study also showed no
had 4.12 times the risk of experiencing hypertension significant relationship between the fat intake level
than those with a sufficient amount of sleep. This is and hypertension. This corresponds with studies which
similar to the research which showed a significant stated there was no significant relationship between
relationship between the sleep duration and blood the fat intake level and hypertension 11,22. Moreover,
pressure in adolescents19. The biological mechanisms of the present study showed no significant relationships
a poor quality of sleep causing hypertension are not between the fruit and vegetable consumption levels and
known with certainty, but they may be related to a hypertension. Angesti also showed that there were no
cortisol secretion disturbance. The stimulation of the significant relationships between the fruit and vegetable
renin- angiotensin system and the sympathetic nervous consumption levels and hypertension21. Contrarily,
system due to an increase in catecholamine secretion can a study showed the adolescents who consumed less
cause hypertension; therefore, adolescents with a poor vegetables had a systolic blood pressure 1.0 times and
sleep quality may exhibit a homeostasis system a diastolic blood pressure 0.8 times higher. Additionally,
disruption. This disruption can result in increased brain those who consumed less fruit can had a systolic blood
activity, thus, results in the secretion of various
pressure 1.3 times higher and a diastolic blood pressure
hormones. These hormones (epinephrine and
1.9 times higher24.
norepinephrine) can affect the peripheral resistance, and
factors combined can increase the blood pressure. One This study showed no significant relationship
study showed there were no significant differences between water consumption level and hypertension.
between the genetic factors with regard to These results oppose the studies conducted in Bandung
hypertension20. Additionally, a study reported there was which showed drinking more water contributed to
no significant relationship between genetic hypertension prevent hypertension. Drinking more water results
and hypertension it self1. However, Angesti showed a in greater water absorption in every cell of the body,
significant relationship between a family history which is a catalyst for metabolic processes. Improving
hypertension and hypertension. The students with family the transportation system accelerates the screening
hypertension histories had a 3.19 times greater risk of process, increases reabsorption in the glomerulus, and
developing hypertension21. Similarly, the results of a accelerates the excretion of metabolic wastes and toxic
study showed a significant relationship between a substances25. Thus, water can help maintain the body
family hypertension history and the development of organ functions and prevent hypertension. There was
hypertension13. The statistical test results showed no no significant relationship between the physical activity
significant relationship between the sodium intake level level and hypertension in the present study. These
and hypertension. This corresponds to a study which results correspond the study by Roberta, which showed
showed no significant relationship between the sodium no significant relationship between the physical activity
intake and hypertension21. However, two studies showed level and hypertension14. Contrarily, a study conducted
a significant relationship between them12,22. Moreover, on high school students in Banjarmasin, and a study
the results showed no significant relationship between conducted in Europe, showed the physical activity level
the potassium intake level and hypertension. This did exhibit a significant relationship with the risk of
also corresponds with research conducted by Angesti, high blood pressure26,10. The results of statistical tests
which showed no significant relationship between the showed no significant association between the stress
potassium intake and hypertension21. Contrarily, the
level and hypertension. This opposes the results study hypertension and how to avoid it. Future research should
in Banjarmasin who showed a significant relationship incorporate a stronger research study design including
between stress and the high blood pressure risk in causal relationships, such as a cohort study.
adolescents; the stressed adolescents had a 9.3 times
higher risk of hypertension26.These results are similar to Acknowledgment
a study which showed there was a significant
relationship between stress level and the risk of high The authors are grateful to all participants who
blood pressure17. The results of the logistic regression trusted the research team, and the student volunteers
analysis showed the sex, BMI/A, and sleep duration who provided support during the data collection process,
exhibited p values of<0.05 (Table 3). However, the sex ensuring that this study was performed smoothly.
variable had the greatest OR value and chosen as the
Conflict of Interest: The authors declare that there is no
dominant factor associated with hypertension (OR=8.9,
conflict of interest.
95% [1.39-57.08]). It means the male adolescents
exhibited hypertension at a rate of 8.9 times higher than Source of Funding: This study was self –funded.
the females, after controlling for the family hypertension
history, BMI/A, fruit consumption level, vegetable Ethical Clearence: Ethical approval was obtained from
consumption level, physical activity level, and sleep the Institutional Review Board of the Faculty of Public
duration. Health at the Universitas Indonesia (No. 320/UN2.F10/
PPM.00.02/2018, April 25 2018). Written consent was
obtained from all of the participants.
Table 3: Multivariate Analysis

p 95% CI REFERENCES
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DOI Number: 10.5958/0976-5506.2019.01710.8

Discogenic Low Back Pain, Diagnostic Criteria

Mahmoud Ramadan Adly1,2, Ahmed Hossameldin Hussein1,3, Omyma Sayed Mahmoud4

Neurosurgery Department, KasrAlainy Medical School, Cairo University, Egypt; 2Neurosurgery
1

Department, Faculty of Medicine, Beni-Seuf University, Egypt; 3Neurosurgery Department, Faculty of

Medicine, Fayoum University. Egypt; 4Radiology Department, Faculty of Medicine, Beni-Seuf University,
Egypt

ABSTRACT
Background: Diagnosis of discogenic low back pain is challenging process as a most common cause of
low back pain. It is a matter of debate and concern for all health professionals involved, particularly spine
surgeons. the aim of this study to establish a specific criteria for diagnosing discogenic LBP.
Patients and Method: This our study was carried on 88 patients suffering low back pain suspected to be
discogenic in nature which were diagnosed clinically and radiological investigations, clinically We asked
patients whether they experienced LBP after sitting too long, while standing after sitting too long,
squirming in a chair after sitting too long, and in the standing position with flexion. Also, we examined
patient if they have midline tenderness (centralization phenomenon) or not. Rather than classic picture of
degenerated disc radiologically as back and bulging discs we analyze mri for high intensity zone in
lumbosacral spine MRI. We exclude patient with lumbar spinal stenosis, spondylolisthesis and patient with
post-operative lumbar surgery back pain.
We analyzed specific criteria clinically and radiologically for diagnosing discogenic
LBP.
Results: We can obtain the precise diagnosis of discogenic low back pain standing on our clinical
and
radiological criteria.
Clinically: Medical history and Physical examination: Mainly four criteria
LBP after sitting too long: All patients experienced LBP after too sitting, it is significant indicator
for
discogenic LBP.
Squirming in a chair after sitting too long: There is significant relationship between Squirming
during
sitting and discogenic back pain, P value is highly significant as it is 0.000
LBP in the standing position with flexion: There is significant relationship between LBP in standing with
flexion and DLBP, P value is significant as it is
0.014.
Centralization phenomenon (CP): All cases have midline tenderness on examination as specific signs or
discogenic back pain. We suggested that the CP is a diagnostic indicator of
DLBP.
Radiologicaliy: Magnetic resonance imaging (MRI) is by far the most useful and the most commonly used
method for diagnosing DLBP. an MRI of DLBP shows low signal intensity of the disc on T2W, a high-
intensity zone (HIZ) at the rear of the disc, and end plate changes. Low signal intensity of the disc on
sagittal T2W. However, P-value is not significant, 60% of patients have high intensity zone in MRI
L.S.S which considered to be useful in determining symptomatic level.
Conclusion: All three questions, centralization phenomenon and high intensity zone in MRI Lumbosacral
spine were useful and specific for diagnosing discogenic
LBP.

Keywords: Dicogenic low back pain – degenerated disc disease – centralization phenomenon.
1004 Indian Journal of Public Health
IndianResearch
Journal &
of Development,
Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1004

Introduction LBP treatments are often unsatisfactory due to the lack

of a precise diagnosis. Good history taking, clinical
Low back pain (LBP) became one of the leading
examination and investigation.
problems in public health systems in the western world
during the second half of the 20th century. [1]. Most people
will experience back pain at some point in their lives. It Patient Assessment
is estimated that an individual has an 80% probability of The assessment of a patient who has low back
having low back pain at some period during his lifetime. pain begins with history taking, followed by a physical
[2]
examination. There are certain red flags on history and
It has been difficult to identify the cause of LBP. A physical examination that warrant immediate evaluation
specific source of pain can be identified in some cases of and diagnostic testing. If a red flag has shown,
LBP; however, the source cannot be identified in other appropriate action must be taken including urgent
cases of LBP (i.e., non- specific LBPMagnetic resonance surgical intervention at the same day.
imaging (MRI) can identify underlying pathologies of
Red flags on history and physical examination that
LBP. However, the importance of MRI findings is
should lead to immediate investigation and
unclear and controversial. Some reports have shown that
treatment:
disc degeneration was a source of LBP 3whereas other
reports have shown that there was no relationship z Cauda equina syndrome (the most important).
between disc degeneration and LBP [4]. Reports have also z Age less than 20 years or greater than 55 years.
shown that discogenic LBP associated with degenerative
disc disease (DDD) is confirmed by the MRI findings z Trauma.
and response to the injection of contrast media or z Malignant disease (multiple myeloma, lymphoma,
local anaesthesia into the disc [5]. Schwarzer et al. primary epidural or intra dural tumor) or metastatic
reported that 39% of cases of chronic LBP are disease.
discogenic, and the diagnosis is made by computed
z Treatment with glucocorticoids.
tomography after discography [6]. The technique of
injecting local anaesthesia into a disc is analgesic z IV drug abuse, alcohol abuse.
discography (discoblock). However, these procedures do
z HIV infection.
not necessarily indicate high specificity findings of
discogenic LBP [7], and they are invasive and harmful to z Unexplained weight loss.
the disc [8]. z Unexplained fever.
We hypothesized that discogenic LBP is one of the z Constant pain that is worsening over time.
causes of LBP, and we sought to determine easier and z Progressive neurologic deficit.
less invasive means of diagnosing discogenic LBP. Few
reports have specified that LBP in the sitting position Diagnosis of discogenic low back pain: We can obtain
can indicate discogenic LBP [9]. The purpose of the the precise diagnosis of discogenic low back pain by the
current study was to evaluate the usefulness of our following:
original questions in a medical interview about LBP
A. Clinically: Medical history and Physical
and radiologically criteria also, which was intended to
examination: Mainly five criteria
determine the characteristics of discogenic LBP and
establish a support tool for diagnosing discogenic LBP. 1. LBP after sitting too long
2. squirming in a chair after sitting too long.
Discogenic Low Back Pain (DLBP): Because of
3. LBP in the standing position with
the variety of anatomic and pathophysiologic causes flexion.
of chronic low back pain, it is a difficult diagnosis
4. Location: Centralization phenomenon (CP):
for clinicians to make. Only a small proportion
(approximately 20%) of LBP cases can be attributed We examined patient if they have midline
with reasonable certainty to a pathologic or anatomical tenderness (centralization phenomenon) or not.
entity. Thus, diagnosing the cause of LBP represents Mckenzie in 1981 first described the centralization
the biggest challenge for doctors in this field. Persistent phenomenon, which consists of pain in the
central line of the spine upon lateral movement. a ‘high-intensity signal’ (bright white) located in the
The mechanism of the CP showed that Spinal posterior annulus fibrosus. It is clearly dissociated from
movements may return the displaced or removed the signal of the nucleus pulposus in that it is surrounded
nucleus to its normal position along the crack of superiorly, inferiorly, posteriorly and anteriorly by the
the disc, resulting in pain along the central line of low-intensity (black) signal of the annulus fibrosus and
the spine. is appreciably brighter than the signal of the nucleus
B. Radiological studies: Magnetic resonance (Figure 2).
imaging (MRI) is by far the most useful and The A close association between HIZ and disc pain
most commonly used method for diagnosing was observed in some studies. It is suggested that
DLBP. an MRI of DLBP shows low signal inflammation of the annular fibrosus fissure causes
intensity of the disc on T2W, a high-intensity the HIZ to appear, and this inflammation also causes
zone (HIZ) at the rear of the disc, and end plate irritation of pain fibers. The presence of the HIZ has a
changes. Low signal intensity of the disc on sensitivity of 82%, a specificity of 89%, and a positive
sagittal T2W. Age-related disc degeneration is predictive value of 90% for DLBP. Peng et al.found that
associated with nucleus dehydration and matrix the HIZ had a 100% sensitivity and specificity for discs
degradation, causing the T2W MRI signal classified as having a grade 3 tear according to the
intensity to decrease and resulting in a “black Dallas discogram description. Overall, most clinicians
disc”, Sagittal T2- weighted images are best for consider the presence of the HIZ is a good indicator for
evaluating disk water content (Fig. 1) DLBP.

Figure 1: Sagittal T2-weighted magnetic resonance

image demonstrating disk height collapse and loss of
T2 signal within theL4-5 and L5-S1 disks. Note also
the reactive end plate changes and overall loss of
lumbar lordosis.

Rather than classic picture of degenerated disc in

MRI as black and bulging disc we analyze MRI L.S.S
for high intensity zone in the degenerated discs.
Figure 2: Sagittal T2-weighted magnetic resonance
High-intensity zone (HIZ): In 1992, Aprill and Bogduk
image (MRI) shows a high-intensity zone (arrow)
first described what is now known as the High- intensity within the posterior annulus at L4-L5 Axial T2-
zone (HIZ) seen on MRI of the lumbar spine. HIZ was weighted MRI shows a high-intensity zone (arrow)
within the posterior annulus at L4-L5
Results 3. LBP-standing with flexion: There is significant
1. LBP after sitting too long: All patients relationship between LBP in standing with flexion
experienced LBP after too sitting, it is significant and DLBP, P value is significant as it is 0.014.
indicator for discogenic LBP. 4. Local Midline tenderness: All cases have
2. Squirming in a chair after sitting too long: midline tenderness on examination as specific
There is significant relationship between signs or discogenic back pain. We suggested that
Squirming during sitting and discogenic back the CP is a diagnostic indicator of DLBP.
pain, P value is highly significant as it is 0.000

Table 1: Relation between discogenic low back pain and LBP after sitting too long- and P-value.
Negative Positive
Count 41 47 88
LBP-sitting % within LBP-sitting 46.6% 53.4% 100.0%
Total Count 41 47 88
% within LBP-sitting-Pre 46.6% 53.4% 100.0%

Value Df p value
McNemar-Bowker Test . . .(a)
N of Valid Cases 88
a. Computed only for a PxP table, where P must be greater than 1.

Table 2: Relation between discogenic low back pain and squirming in a chair after sitting too long -and P-value
Squirming-sitting
Negative Positive Total
Count 6 3 9
Negative % within Squirming-sitting- 66.7% 33.3% 100.0%
Squirming- % within Squirming-sitting 13.0% 7.1% 10.2%
sitting Count 40 39 79
Positive % within Squirming-sitting- 50.6% 49.4% 100.0%
% within Squirming-sitting 87.0% 92.9% 89.8%
Count 46 42 88
Total % within Squirming-sitting- 52.3% 47.7% 100.0%
% within Squirming-sitting 100.0% 100.0% 100.0%
Value p value
McNemar Test .000(a)
N of Valid Cases 88
a. Binomial distribution used, b. Group = PRF

Table 3: Relation between discogenic low back pain and LBP-standing with flexion - and P-value

LBP-standing with flexion

Total
Negative Positive
Count 29 9 38
Negative % within LBP-standing with flexion 76.3% 23.7% 100.0%
LBP-standing % within LBP-standing with flexion 54.7% 25.7% 43.2%
with flexion Count 24 26 50
Positive % within LBP-standing with flexion- 48.0% 52.0% 100.0%
% within LBP-standing with flexion 45.3% 74.3% 56.8%
Count 53 35 88
Total % within LBP-standing with flexion 60.2% 39.8% 100.0%
% within LBP-standing with flexion 100.0% 100.0% 100.0%
Value p value
McNemar Test .014(a)
N of Valid Cases 88
a. Binomial distribution used.

Table 4: Local Midline tenderness

Group
Local Count 88 100
Midline Yes % within Local Midline Tenderness 50.0% 100.0%
tenderness % within Group 100.0% 100.0%
Count 88 100
Total % within Local Midline Tenderness 50.0% 100.0%
% within Group 100.0% 100.0%
5. High intensity zone in MRI L.S.S: However, Centralization phenomenon (CP): All cases
60% of patients have high intensity zone in MRI have midline tenderness on examination as
L.S.S but P-value is not significant. specific signs or discogenic back pain. We
suggested that the CP is a diagnostic indicator of
Table 5: high intensity zone DLBP.
B. Radiologicaliy: Magnetic resonance imaging
High intensity zone Positive Negative Total
(MRI) is by far the most useful and The most
Count 53 35 88 commonly used method for diagnosing DLBP.
Percentage % 60% 40% 100% an MRI of DLBP shows low signal intensity of
p-value 0.55 the disc on T2W, a high-intensity zone (HIZ) at
the rear of the disc, and end plate changes. Low
Discussion signal intensity of the disc on sagittal T2W.
However, P-value is not significant, 60% of
Because of the variety of anatomic and patients have high intensity zone in MRI L.S.S
pathophysiologic causes of chronic low back pain, it which considered to be useful in determining
is a diffcult diagnosis for clinicians to make, We can symptomatic level.
obtain the precise diagnosis of discogenic low back pain
standing on our clinical and radiological criteria. Conclusion
A. Clinically: Medical history and Physical To conclude we hypothesized 5 criteria specific for
examination: Mainly four criteria discogenic low back pain:
LBP after sitting too long: All patients z LBP after sitting too long,
experienced LBP after too sitting, it is significant
indicator for discogenic LBP. z squirming in a chair after sitting too long,
z LBP in the standing position with flexion.
Squirming in a chair after sitting too long:
There is significant relationship between z midline tenderness (centralization phenomenon)
Squirming during sitting and discogenic back z high intensity zone in lumbosacral spine MRI.
pain, P value is highly significant as it is 0.000
LBP in the standing position with flexion: REFERENCES
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19440168
DOI Number: 10.5958/0976-5506.2019.01711.X

Ultrasound Guided Enhanced Recovery Program in Colorectal

Surgery: Kasralainy Modified Protocol

Ahmed FA Farag1, Hany MS Mikhail1, Hamed H Elsheshiny1, Moataz F Mohamed2, Osama RM Refaie1,
Haitham SE Omar1, Ahmed MSM Marzouk1
1
Department of General Surgery, 2Department of Internal Medicine and Radiology, Cairo University
Medical School, KasrAlainy, Egypt

ABSTRACT
Enhanced recovery after surgery (ERAS) protocols were created to improve patient recovery and to reduce
the postoperative hospital stay and comorbidities. Temporary postoperative gastrointestinal dysfunction,
as nausea, vomiting, or abdominal distension, is a common morbidity after abdominal surgery that
largely determines clinical recovery and hospital stay.Currently, the diagnoses of temporary postoperative
GI.dysfunction and paralytic ileus are based on subjective reporting of clinical symptoms. In our study an
objective assessment tool to identify temporary postoperative GI. dysfunction and paralytic ileus, as well as
their resolution was used and the results showed that ERAS combined with abdominal ultrasound used for
the care of patients undergoing colorectal surgery is improving standards of care by reducing postoperative
hospital stay, attempting to improve the overall quality of recovery, decrease the percentage of
postoperative vomiting, cost saving, and patient satisfaction.

Keywords: Ultrasound, ERAS, Colorectal, Cancer, PONV,

Recovery.
Introduction Dysfunction may be prolonged (≥4 days), resulting
in prolonged paralytic ileus 14, that may reported to affect
Enhanced recovery after surgery (ERAS) protocols
about 14% of patients after major colorectal surgery15,
were created to improve patient recovery by the early
Currently, the diagnoses of temporary postoperative
restoration of normal physiological function, and by
GI. dysfunction and paralytic ileus are based on
decreasing the surgical stress response. The result
subjective reporting of clinical symptoms. Therefore,
was reducing the postoperative hospital stay and
a more objective assessment tool to identify temporary
comorbidities. Data regarding the effect of ERAS on
postoperative GI.dysfunction and paralytic ileus, as well
complications are conflicting; Some randomized trials
as their resolution, is desirable to assist with the safe
have reported no differences in the complication rate1–
postoperative introduction progression of oral intake. 16
6
. however, other studies showed a reduction in minor
complications only with ERAS protocols but not in
major complications 7-12. Temporary postoperative Patient and Method
gastrointestinal dysfunction, as nausea, vomiting, or This is a randomized control study which was
abdominal distension, is a common morbidity after registered with Pan African Clinical Trial Registry
abdominal surgery that largely determines clinical (PACTR20180600337298). The study included sixty
recovery and hospital stay13. patients, aged 18 or above who were treated with
elective laparoscopic colorectal surgery for malignant or
benign disease, with or without stoma, at Cairo
university hospitals, (KasrAlainy), Cairo, in the period
Corresponding Author:
between March 2017 to February 2018.
Osama RM Refaie
Department of General Surgery, After the agreement of the scientific and ethical
Cairo University Medical School, KasrAlainy, Egypt committee of the general surgery department, the
Email: [email protected] procedure and the study were explained for all
individuals
1010 Indian Journal of Public Health
IndianResearch
Journal &
of Development,
Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1010

participating in the study and all of them consented Data were coded and entered using the statistical
for agreement. Patients below 18 years old, patients package SPSS (Statistical Package for the Social
with previous history of major abdominal surgery, Sciences) version 25. Data was summarized using mean,
patients with electrolyte imbalance as hypokalemia, standard deviation, median, minimum and maximum
haemodynamically unstable, peritonitis, and emergency in quantitative data and using frequency (count) and
operations were excluded from the study. relative frequency (percentage) for categorical data.
Comparisons between quantitative variables were
The 60 patients randomized into two groups (A and done using the non-parametric Mann-Whitney test.
B) using closed envelop technique. Neither patients nor For comparing categorical data, Chi square (χ2) test
physicians were blinded to the group assignment was performed. Exact test was used instead when the
because of the nature of the study. Group A included 30 expected frequency is less than 5. P-values less than
patients who were allowed to have oral fluid intake on 0.05 were considered as statistically significant.
the first day postoperative and built up to an oral diet
over the next 24 hours postoperatively. Group B Results
included 30 patients who had abdomino-pelvic Both groups were matched regarding the age and
ultrasound 24 hours after surgery using abdominal probe gender. The mean age for group A was 51.80 ± 12.95
3.5 M.H.Z. at least for 10 minutes to assess while group B was 49.57 ± 11.65 (p >0.05).
gastrointestinal motility. Once the intestinal motility
recognized the patient allowed to initiate the oral fluid All patients in group A (100%) started oral fluid in
day 1 while only (80%) of group B started oral fluid in
and then allowed to start soft diet as tolerated. If there is
the first postoperative day after assessment of good
no intestinal motility the ultrasound was repeated every
G.I.T motility by U/S. the rest of the patients of group B
12 hours until the presence of good gastrointestinal
(20%) started oral fluid after reassessment of G.I.T
motility.
motility by U/S in day 2. with significant statistical
All patients were counseled and trained Pre- difference between the two groups (p >0.05).
Regarding the start of soft diet, 80% of patients in
operatively for the concept of ERAS, and curtailed
group A started soft diet at day two, 10% of patient at
fasting. The patients should be fasted for 6 hours to
day three, and 10% at day four after toleration of oral
solids but they were allowed to have small amounts of
fluid. On the other hand, 70% of patients in group B
clear free fluids for up to 2 hours before induction of started soft diet at day two, 26.7% at day three, and
general anesthesia. In addition, a clear carbohydrate rich 3.3% at day four after toleration of oral fluid. (p >0.05)
drink should be administered orally (100 g.) the night
before surgery and (50 g.) 3 hours prior to induction There is significant statistical difference between
of anesthesia. A single dose of prophylactic antibiotics the
two groups regarding the postoperative vomiting (p <0.05)
(ceftriaxone 1 gm. and metronidazole 500 mg) was
given 15 min. prior to skin incision, and the second dose The mean post-operative hospital stay of group A
was administrated if the procedure prolonged more than was 3.97 ± 0.64 while group B was 3.36 ± 0.65. with
4 hours, or major blood loss more than 1500 ml. significant statistical difference between the two groups
(p <0.05).
Intraoperative infusion of crystalloids was tailored
The readmission rate to the hospital was the same
to avoid excess fluid administration and volume
(3.3%) in both groups with no significant statistical
overload using goal-directed fluid therapy. intra-
difference between the two groups (p value 1).
abdominal drains were used only when indicated.
Both groups were matching regarding the
Early postoperative mobilization was encouraged perioperative comorbidities as shown in table (1)
with early removal of urinary catheters and NG
tubes and administration of a restricted amounts of 33.3% of patients in group A Pass flatus or stool or
functioning stoma while 53.3% in group B at day
intravenous fluid. A daily regime of 1.5 to 2.5 L. of
one,
balanced intravenous solutions should be prescribed to
43.3% of patients in group A while 36.7%in group B at
avoid excessive fluid administration, sodium overload, day two, and 10% of patients in group A while 23.3%
or hyperchloremic acidosis and delayed return of in group B at day 3 after toleration of oral fluid in both
gut function.. A multimodal, opioid-sparing, pain groups with no significant statistical difference between
management plan was adopted in all patients. the two groups (p >0.05).
Table 1: Showing the summary of the collected data in both groups
Group A Group B
P value
Count % Count %
M 20 66.7% 16 53.3%
Sex 0.292
F 10 33.3% 14 46.7%
HTN 2 6.7% 3 10.0%
DM 3 10.0% 2 6.7%
Medical Hx D.M,AF,Astma 0 .0% 1 3.3% 0.875
D.M, HTN 5 16.7% 3 10.0%
Free 20 66.7% 21 70.0%
D1 30 100.0% 24 80.0%
Start oral Fluid 0.024
D2 0 .0% 6 20.0%
D2 24 80.0% 21 70.0%
Initiation of soft
D3 3 10.0% 8 26.7% 0.218
diet
D4 3 10.0% 1 3.3%
yes 8 26.7% 1 3.3%
Post Op. vomiting <0.05
NO 22 73.3% 29 96.7%
yes 2 6.7% 2 6.7%
readmission 1
NO 28 93.3% 28 93.3%
D1 10 33.3% 16 53.3%
Pass flatus/stool/
D2 13 43.3% 11 36.7% 0.207
functioning stoma
D3 7 23.3% 3 10.0%

Discussion allowed oral fluids as tolerated on the day of the surgery

and built up to an oral diet over the next 24 hours.
This was a randomized control study, which
Patients who are not meeting their nutritional
included sixty patients who presented to the outpatient
requirements by 72 hours after surgery should be
clinic of the colorectal unit in KasrAlainy hospital in
assessed by a dietician.
the period between March 2017 to February 2018 for
colorectal surgery. The result in this study showed that the oral intake
is more tolerated when using an objective method
The purpose of this study was to evaluate the role
of abdominal and pelvic ultrasound in ERAS to assess (ultrasound) to assess the gastrointestinal motility,
the gastro-intestinal motility after colorectal surgery, and this was suggested by significant statistical difference
its effect on the postoperative hospital stay, PONV and between the two groups regarding to the postoperative
readmission rate. vomiting (p <0.05). The undesirable postoperative
GIT dysfunction, manifesting as nausea, vomiting,
In this study, all patients were in group A (100%) or abdominal distension, is a common morbidity after
started oral fluid in day 1 (under right scenario of ERAS in abdominal surgery that largely determines
ERAS. technique), while only (80%) of group B patients
clinical recovery and hospital stay13. However the cause
were started oral fluid after assessment of good G.I.T
of vomiting is multifactorial and can be classified into
motility by US and the rest of the patients of group B
(20%) were started oral fluid after reassessment of good three factors: patient, anesthetic and surgical 18,19
G.I.T. motility by US. in day 2. There was a significant
This study showed that 80% of patients in group A
statistical difference between the two groups (p>0.05).
were started soft diet while 70% in group B at day two.
This study matched with what was reported by While 10% of patients in group A while 26.7% in group
Andersen and his colleagues17that, patients should B at day three, and 10% of patients in group A
be while
3.3% in group B at day four after toleration of oral fluid
in both groups with no significant statistical colleague 23
and Thanh and his colleagues 24
that
difference have
between the two groups (p >0.05).

These results were matched with what were

reported that, early introduction of diet and fluids within
24 hours post-operatively has been shown to be safe
20
. Also compatible with Ljungqvist and his
colleaguethat patient progressing normally on an ERAS
pathway should be drinking, eating and mobilizing on
the day after operation to minimize stress, improve the
response to stress and maintaining homeostasis. The
early feeding encourage the patient to avoid
catabolism with consequent loss of protein, muscle
strength, cellular dysfunction and avoiding several
traditional care elements.21,22

The results in this study showed that 33.3% of

patients in group A (patients under ERAS. technique)
passed flatus or stool or functioning stoma while 53.3%
in group B (patients under ERAS. technique combined
with US.) at day one. While 43.3% of patients in group
A, and 36.7% in group B at day two, and 10% of
patients in group A while 23.3% in group B at day 3
after toleration of oral fluid in both groups with no
significant statistical difference between the two groups
(p >0.05). Although there were no significant statistical
difference between the two groups, but the chance
postoperative passage of flatus or stool or functioning
stoma in group B where higher than group A. It may
need a larger patient sample to be significant.

These results were matched with what were

reported that, The tolerance to early feeding provides a
more objective evaluation of gut function than
assessment on the basis of bowel sounds of passage of
flatus 20.

The result of this study showed that the two studied

groups had similar readmission rate to the hospital
(6.7%), with no significant statistical difference between
the two groups of patients under ERAS technique, and
patients under ERAS technique combined with US. (P
value 1).

The results in this study showedthat, the mean

post-operative hospital stay of group A was (3.97 ±
0.64) while group B was (3.36 ± 0.65). There was a
significant statistical difference between patients under
ERAS. technique, and patients under ERAS. technique
combined with US. (p <0.05). These results were
matched with what were reported by Carmichael and his
been reported, colorectal surgery under ERAS technique
had better outcomes as quicker return of bowel function,
shorter hospital lengths of stay, and return of
investments of at least 240%.

ERAS combined with abdominal ultrasound used

for the care of patients undergoing colorectal surgery
provides improved standards of care by reducing
postoperative hospital stay, attempting to improve the
overall quality of recovery, decrease the percentage
of postoperative vomiting, cost saving, and patient
satisfaction.

Source of Funding: Self-funding

Ethical Clearance: Cleared by the ethical committee of

General surgery department faculty of medicine Cairo
University

Conflict of Interest: No

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no. NCT00123456). ClinNutr. 2009;28:618–624. 19. Gustafsson U.O., Scott M.J., Schwenk W.,
9. Wang G, Jiang ZW, Zhao K, et al. Fast track Demartines N., Roulin D., Francis N., McNaught
rehabilitation programme enhances functional C.E., Macfie J., Liberman A.S., Soop M., Hill
recovery after laparoscopic colonic resection. A., Kennedy R.H., Lobo D.N., Fearon K., and
Ljungqvist O.: Enhanced Recovery After Surgery
Hepatogastroenterology. 2012;59:2158–2163.
(ERAS) Society for Perioperative Care; European
10. Wang Q, Suo J, Jiang J, Wang C, Zhao YQ, Cao Society for Clinical Nutrition and Metabolism
X. Effectiveness of fast-track rehabilitation vs (ESPEN); International Association for Surgical
conventional care in laparoscopic colorectal Metabolism and Nutrition (IASMEN). Guidelines
resection for elderly patients: a randomized trial. for perioperative care in elective colonic surgery:
Colorectal Dis. 2012;14:1009–1013. Enhanced Recovery After Surgery (ERAS Society
11. Greco M, Capretti G, Beretta L, Gemma M, recommendations.World J Surg. 2013; 37(2):259-
Pecorelli N, Braga M. Enhanced recovery 284.
program in colorectal surgery: a meta-analysis 20. Lewis S. J., Andersen H. K., and Thomas S.:
of randomized controlled trials. World J Surg. Early enteral nutrition within 24 h of intestinal
2014;38:1531–1541. surgery versus later commencement of feeding:
12. Spanjersberg WR, Reurings J, Keus F, van a systematic review and meta-analysis. J.
Laarhoven CJ. Fast track surgery versus Gastrointest. Surg. 2009 Mar;13(3):569-75.
conventional recovery strategies for colorectal 21. Ljungqvist O., and Jonathan E.: insulin resistance
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B.: Clinical Practice Guidelines for Enhanced
14. Vather R., Trivedi S., and Bissett I.: Defining
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DOI Number: 10.5958/0976-5506.2019.01712.1

The Use of Intra-articular Steroid Injection to improve

functional outcomes in Tibial Plateau Fractures

Sherif Hamdy Mohamed Zawam1, Ahmad Salah Muhammad Abu Taleb1

1
Department of Orthopedics, Faculty of medicine, Cairo University, Cairo, Egypt

ABSTRACT
Tibial plateau fractures should be properly managed, otherwise, they may end up in serious complications.
These complications include limitation of movements, osteoarthritis and may finally result in joint stiffness.
From February 2017 to August 2017, a study was conducted including 30 patients with united tibial plateau
fractures to evaluate the role of intra-articular corticosteroid injection in improving the clinical outcomes
after open reduction and internal fixation. Ten patients had Schatzker type I tibial plateau fractures, 13
patients had Schatzker type II and seven patients had Schatzker type III fractures. Average follow-up was
13.5 months. The average total clinical Rasmussen score was 28.3. It was excellent in 19 cases, and 11
cases
had good results.

Keywords: Tibial plateau fractures, corticosteroids injection, functional

outcomes.
Introduction Materials and Method

Tibial plateau fractures represent an important entity From February 2017 to August 2017, 30 patients
in orthopedic surgery. Nowadays, most tibial plateau with tibial plateau fractures were enrolled in this study.
fractures are managed by open reduction and internal Regarding the mechanism of the injury, 12 patients
fixation. However, in some cases with non-displaced (40%) fell to the ground, 11 patients (36.7%) had road
fractures, conservative treatment may be adopted. traffic accidents injury, and 7 patients (23.3%) fell from
The most common complications of tibial plateau height. The study included 12 male patients (40%)
fractures, regardless the way of management, are knee and
pain, limitation of movements, osteoarthritis and joint 18 female patients (60%). The mean age was 48.5 years,
stiffness.1,2 ranging from 41-58 years. Ten patients had Schatzker
type I tibial plateau fractures (33.3%), 13 patients
The main cause of pain and limitation of movement
(43.3%) had Schatzker type II and seven patients
is the immobilization that follows the fracture, either
(23.3%) had Schatzker type III fractures. The patients
treated operatively or conservatively. Also, the
were fully assessed by proper history taking and full
disruption of the articular cartilage plays an important
physical examination. The patients were admitted in the
role, together with the intra-articular inflammatory
hospital after completing the primary, secondary and
process following the trauma or the operation.3
tertiary surveys.5
Corticosteroids were used for intra- articular
The following table shows the patients
injection many years ago. Their role in controlling
demographics. (Table 1)
the inflammatory process and improving the range of
motion in patients with osteoarthritis is well known and
established. 4 Table 1: Patient Demographics

The aim of our study was to evaluate the role of Variable No.
intra-articular corticosteroid injection in improving the Total no. of Patients 30
outcomes of patients with united tibial plateau fractures Average age, (range) years 48.5 years, (41-58) years
treated by open reduction and internal fixation. Gender :Male 12(40%)
Female 18(60%)
1015 Indian Journal of Public Health
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Research No. 7 July 2019, Vol.10, No. 7
Development, 1015

Conted… physiotherapy with anti-inflammatory modalities. The

patients were followed up every 3 months, until the final
Side: -Right 16(53.3%)
-Left 14(46.6%) assessment was done one year post-operatively.
Mode of trauma: Fall to the The patients were assessed according to modified
ground 12 patients (40%) Rasmussen scoring system.6 (Table 2)
Road traffic accidents 11 patients (36.7%)
injury 7 patients (23.3%)
Fall from height Results

Above knee slabs were used until the time of The patients were followed up for an average of
the 13.5 months postoperatively (range from 12 months
operation which was performed after an average of to
4 days. The patients were treated by open reduction 15 months). Regarding the pain, twenty patients were
and internal fixation using either plates and screws or pain free, two patients had occasional pain, and eight
screws only. The patients were put in above knee slabs patients had stabbing pain in certain positions. (Fig. 3)
for another 2 weeks. Then, the slabs were removed and
Twenty five patients had normal walking capacity
the patients were instructed to start range of motion. The
for age. Three patients could walk outdoors for more
patients were followed up until clinical and radiological
than one hour, and two patients could walk outdoors
union, which occurred at an average of 8.9 weeks.
from (fifteen minutes to one hour).
Clinically, there was minimal to no tenderness at the
fracture site. Radiologically, union was determined by Twenty five patients had normal knee extension.
the disappearance of the fracture gap and continuity Four patients had lack of extension less than ten degrees,
of the fracture lines. (Fig. 1) After that, intra-articular and another one had lack of extension more than ten
injection of corticosteroids was done. degrees.

The procedure was done under complete aseptic Regarding the total range of motion, twenty three
conditions. It was done in the room specialized for patients had full range of motion, five patients had at
minor procedures in the operating theater. Sterilization least 120 degrees, and two patients had at least ninety
and surgical draping was done using betadine solution. degrees. (Fig. 4)
Standard anterolateral (soft spot) entry point was used
for injection. (Fig. 2)

A B
Fig. 1: (a) Pre-operative x-ray anteroposterior view
showing Schatzker type III tibial plateau fracture,
(b) X-ray after union.

Then, using a spinal cannula, 4mg of

dexamethasone was injected intra-articularly. Gentle Fig. 2: The marker sign shows the site of intra-
physiotherapy was done for one week, followed by articular injection (soft spot).
active and passive
Table 2: Modified Rasmussen scoring system.6 DISCUSSION
Parameter Score Historically, a patient with comminuted tibial
Maximum score 30
Excellent 28-30 plateau fractures was thought to permanently lose some
Good 24-27 functions of the injured knee. With the development of
Fair 20-23 new techniques of reduction and fixation, this concept
Poor <20 started to diminish. However, nowadays, patients with
tibial plateau fractures even if properly managed may
suffer from some complications.7

These complications include persistent pain, limited

range of motion, either flexion or extension. This may
even end up in stiffness. This is attributed mainly to the
inflammatory process and the cartilaginous disruption
that occurs with the traumatic episode.7

Fig. 3: Final Patients Pain Status

Twenty-eight patients had normal stability in

extension and in 20º flexion, and two patients had
abnormal stability in 20 ºflexion. The power of
quadriceps in twenty five patients had grade V power.
Five patients had grade III-IV quadriceps power.

The average total clinical Rasmussen score was

28.3. It was excellent in 19 cases, and 11 cases had good Fig. 5: Average Clinical Rasmussen Scores
results. (Fig. 5)
Corticosteroids have been long used in the treatment
of osteoarthritis. Dexamethasone is one of the most
potent members of the steroids family. It is about 25
times more potent than hydro-cortisone. They are used
systemically to treat a wide range of auto-immune
diseases. However, their use was limited with their
adverse effects, such as impairing blood glucose level,
and impairing the vascularity of certain bones such as
the head of the femur or the distal end of the femur.
Also, the adverse effects include increasing the body
weight, cardiovascular diseases, and increasing the
susceptibility of infection. The use of intra-articular
injection avoids these risk factors, especially, if not
repeated frequently. Dexamethasone performs its anti-
inflammatory effects through inhibition of
metalloproteases, prostaglandins, and oxygen free
radicals. 4, 8

Lu et al., described the role of dexamethasone in

protection of injured cartilage. It acts by normalization
of the glycosaminoglycans release from the injured
cartilage as a response to tumor necrosis factor alpha. 9

Fig. 4: Final Range of motion showing (a) full flexion Sofi et al., assessed the efficacy of Injection of
and (b) full extension steroids intra-articularly in patients with osteoarthritis.
They concluded that corticosteroids provide good
pain
relief and improved the functional outcomes in patients Ethical Clearance: The paper was accepted and
with osteoarthritis. They didn’t find any osteopenia in approved by the ethical committee.
radiographs as an adverse effect. 10

Our study included 30 patients with tibial plateau

fractures, 12 males and 18 females with mean age of
48.5 years. The aim of our study was to evaluate the
role of intra-articular corticosteroid injection in
improving the outcomes of patients with united tibial
plateau fractures treated by open reduction and internal
fixation.

The patients were followed up for an average

of
13.5 months postoperatively (range from 12 months
to
15 months). The average total clinical Rasmussen score
was 28.3. It was excellent in 19 cases (63%), and 11
cases (37%) had good results.

When comparing our results to other studies on

tibial plateau fractures that didn’t utilize intra-articular
injection, we found that our study yielded relatively
better scores. Chiu CH et al. operated on 25 patients with
tibial plateau fractures. The average clinical Rasmussen
score was 25.9. Eleven patients (44%) had excellent
results, 12 patients (48%) had good results, and two
patients (8%) had fair results.11 Siegler et al., operated on
27 patients, the average clinical Rasmussen score was
25.5. 12

Conclusion

Intra-articular corticosteroids injection is thought

to improve the pain, function, and final outcomes in
patients with tibial plateau fractures.

They also act to prevent the inflammatory

process that occurs in post-traumatic knee injury. It is
recommended that they should be used more often, but
other comparative studies with longer follow up periods
are recommended.

Conflict of Interest: All authors contributed to

formatting and designing the study as well as revising
the data. All authors actively participated in critically
editing the paper. All Authors approved the final
manuscript before submitting.

Source of Funding: This manuscript presents original

honest work done by the Authors. There are similar
studies done which are presented & referenced in this
study.
REFERENCES
1. Hohl M. Part I: Fractures of the proximal tibia
and fibula. In: Rockwood C, Green D, Bucholz R,
eds. Rockwood and Green’s Fractures in Adults.
Vol 2. 3rd ed. Philadelp hia, PA: JB
Lippincott;
1992:1725-1757.
2. Caspari RB, Hutton PM, Whipple TL, Meyers
JF. The role of arthroscopy in the management of
tibial plateau fractures. Arthroscopy: The Journal
of Arthroscopic & Related Surgery. 1985 Jan
1;1(2):76-82.
3. Kalman DS, Heimer M, Valdeon A, Schwartz
H, Sheldon E. Effect of a natural extract of
chicken combs with a high content of hyaluronic
acid (Hyal-Joint®) on pain relief and quality of
life in subjects with knee osteoarthritis: a pilot
randomized double-blind placebo-controlled trial.
Nutrition journal. 2008 Dec;7(1):3.
4. Rhen T, Cidlowski JA. Antiinflammatory action
of glucocorticoids—new mechanisms for old
drugs. New England Journal of Medicine. 2005
Oct 20;353(16):1711-23.
5. Burdin G. Arthroscopic management of tibial
plateau fractures: surgical technique. Orthopaedics
& Traumatology: Surgery & Research. 2013 Feb
1;99(1):S208-18.
6. Rasmussen PS. Tibial condylar fractures:
impairment of knee joint stability as an
indication for surgical treatment. JBJS. 1973 Oct
1;55(7):1331-50.
7. Boldin C, Fankhauser F, Hofer HP, Szyszkowitz
R. Three-year results of proximal tibia fractures
treated with the LISS. Clinical orthopaedics and
related research. 2006 Apr 1;445:222-9.
8. American Association of Orthopaedic Surgeons
(AAOS) (2013) Treatment of osteoarthritis of the
knee: based guideline – 2nd edtn. Illinois, USA.
9. Lu YC, Evans CH, Grodzinsky AJ. Effects of
short-term glucocorticoid treatment on changes
in cartilage matrix degradation and chondrocyte
gene expression induced by mechanical injury
and inflammatory cytokines. Arthritis research &
therapy. 2011 Oct;13(5):R142.
10. Sofi F, Ahmad M, Bilal A. Arif (2018) Efficacy of
Intra-Articular Steroid Injection in Osteoarthritis
Patients. J Arthritis.;7(269):2.
11. Chiu CH, Cheng CY, Tsai MC, Chang SS, Chen 12. Siegler J, Galissier B, Marcheix PS, Charissoux
AC, Chen YJ, Chan YS. Arthroscopy-assisted JL, Mabit C, Arnaud JP. Percutaneous fixation
reduction of posteromedial tibial plateau fractures of tibial plateau fractures under arthroscopy:
with buttress plate and cannulated screw a medium term perspective. Orthopaedics &
construct. Arthroscopy: The Journal of Traumatology: Surgery & Research. 2011 Feb
Arthroscopic & Related Surgery. 2013 Aug 1;97(1):44-50.
1;29(8):1346-54.
DOI Number: 10.5958/0976-5506.2019.01713.3

Relationship between Hygiene and Sanitation with Coliform

Bacteria Contamination in Refill Drinking Water

Indah Ananda Jamaluddin1, Agus Bintara Birawida1, Ruslan1

1
Faculty of Public Health, Hasanuddin University, Makassar

ABSTRACT
Drinking water is the main source of consumption for the family so it needs to be maintained its quality in
order to avoid Coliform bacteria. Coliform bacteria are suspected to originate from feces, therefore their
presence in various places ranging from drinking water, food ingredients or other materials for human
needs, is not expected. This study aims to get a description of bacterial contamination, depot environmental
sanitation, equipment sanitation, worker hygiene, quality of raw water and refill drinking water in drinking
water depots in BarrangLompo Island, Sangkarang District, Makassar City, 2017. This type of research is
observational with a descriptive approach. The sampling technique uses Grab samples by taking directly
from the tap of the drinking water depot. Water samples were examined using the Most Probable Number
(MPN) method. Data analysis in this study was carried out descriptively and shows that 3 out of 6 depots
have quality refill drinking water that meets the requirements. Raw water samples from all depots show no
one meets the requirements. The samples examined contained gram negative bacteria. The types of
bacteria that grow in the sample are Klebsiella pneumonia and Pseudomonas aerogenosa. On depot
environmental sanitation and worker hygiene no one fulfils the requirements. Equipment sanitation all
meets the requirements and there are depots that use the reserve osmosis method and use a combined
method of reserve osmosis and ultraviolet light. The conclusion of this study is that bacteria are found in
almost all drinking water samples. The bacteria found were Klebsiella pneumonia and Pseudomonas
aerogenosa. Owners and depot workers are advised to improve and implement better hygiene and
sanitation.

Keywords: Hygiene; Sanitation; Coliform Bacteria; Contamination; Refill Drinking

Water
Introduction Higherlevel of Coliform bacterial contamination
means presence the risk of other pathogenic bacteria.
Water is an important material in life and all One example of a pathogenic bacterium that is likely
living things need water. For humans, about 70% of to be contained in water contaminated with human
the substances that make up the human body consist excrement or warm-blooded animals is the Escherichia
of water. Water needs for daily needs are different for coli bacteria, namely microbes that cause symptoms
of diarrhea, fever, abdominal cramps, and vomiting.5
each place and every level of life. Usually the higher the
In addition, the rate of diarrhea is higher by 66% in
standard of living, the higher the number of water children from families who defecate in rivers or sewers
needs.1 than those in households with private toilet facilities and
More than 100 million Indonesians lack access to clean septic tanks.6
water and 150 million contaminated water sources.2 One
Research conducted by Indirawati (2009) shows
effort to meet water needs in Indonesia, the government that there is a significant relationship between sanitation
issued a policy to establish a Regional Water Supply hygiene and microbiological quality of refill drinking
Company (PDAM) which is engaged in the distribution water.7 The Novita (2004) study in Palembang City
and provision of clean water facilities for the general also showed the same results for sanitation hygiene
showed that depot sanitation hygiene had a significant
public.3 Determination of water quality in microbiology
relationship with the quality of drinking water.8 This
is done by the Most Probable Number Test (MPN). If is due to the poor environmental conditions that make
in 100 ml of water samples, Coliform bacterial cells are people worry about consuming ground water.
found to cause diarrhea and other digestive disorders.4
1020 Indian Journal of Public Health
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Journal &
of Development,
Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1020

Based on data at the BarrangLompo Island Health Data Collection: Primary data on sanitation is
Center, Sangkarang Sub-District, Makassar City (2015), obtained directly from the results of interviews using
diarrheal disease is one of the main public health questionnaires and observations by researchers to
problems and is classified as the highest ten diseases. employers or employees who work in Refill Drinking
The number of diarrhea patients in 2013 was 192 Water Depots. Data regarding the quality of refill
people, in 2014 there were 187 people and in 2015 drinking water was obtained through laboratory
there were examination of bacteriological parameters. The
199 people. BarrangLompo Island is one of the islands secondary data was obtained from BarrangLompo Island
within the administrative area of BarrangLompo Sub- Health Center regarding the number of AMIU depots
District. So far, the needs of clean water and drinking operating and registered since 2011 - 2017.
water for residents of BarrangLompo Island have been
met through dug wells, drilled wells and clean water Measurement Method: Hygiene equipment, personal
supply businesses.9 hygiene of workers, environmental sanitation is
measured using an observation sheet. Each of the raw
The number of refill drinking water depots in water and water produced by the depot will be examined
BarrangLompo Island in 2016 was 6 depots of drinking based on bacteriological parameters and the number of
water by using raw water sources from bore wells, samples as many as 12 samples taken 150 ml per sample
which are likely to be contaminated with coliform at each depot.
bacteria. Unlike the raw water source in refill drinking
water depots located in Makassar City which uses raw Data Analysis: Analysis of the data used is descriptive
water sources from the PDAM. The large number of analysis, namely by making a description of the data
DAMIUs that are scattered on BarrangLompo Island obtained from the laboratory and then compared with
the standard RI PERMENKES No. 492/Menkes/Per/
does not guarantee the quality of drinking water
VI/2010 concerning Quality Requirements for Drinking
produced because the method of management and filling
Water to find out whether refill drinking water meets the
of depots cannot always be monitored. As a result,
requirements so that it is suitable for consumption or
many health problems can be caused. Research on
not. And the data obtained from observations and
hygiene of refill drinking water depot workers conducted
interviews are compared with the Decree of the Minister
by Nurmawati et al (2009) showed that there was a
of Industry and Trade of Republic of Indonesia Number
relationship between hygiene of drinking water depot
651/MPP/ Kep/10/2004 concerning the Technical
workers and the number of coliform bacteria.10 Hygiene
Requirements of Drinking Water and Trade Depots to
and sanitation are related to bacterial contamination.
find out whether sanitation depots are eligible or not.
Therefore, this study aims to identify the sanitation
hygiene and bacterial coliform contamination in refill Processing and Presentation of Data: Data obtained
drinking water in BarrangLompo Island, Sangkarang from the results of examinations in the laboratory and
Sub-District, Makassar City, 2017. the results of observations are then processed manually
and presented in the form of tables accompanied by
Methodology explanations.

This study uses observational methods with a

Result and Discussion
descriptive approach.
Coliform Bacteria Contamination in Refill Drinking
Location and Time of Research: The location of the
Water and Raw Water: The number of coliform
study was carried out at the drinking water refill depot
bacteria in refill drinking water was obtained from the
in BarrangLompo Island, SangkarangSubdistrict,
results of laboratory tests with the MPN test with the
Makassar City, and a Microbiology Laboratory, Faculty
standard of the Indonesian Ministry of Health No. 492/
of Medicine, Hasanuddin University. This study was
MENKES/PER/IV/2010. Microbiological parameters
conducted on February - March, 2017.
the maximum level allowed in drinking water are 0 per
Population and Samples: The sample in this study was 100 ml of drinking water. Table 1 shows 3 refill drinking
a refill drinking water depot of 6 depots. The type of water depots that did not meet the requirements of both
sampling is done by Non Probability Sampling, because
the population is relatively small.
raw water and refill drinking water and 3 depots that did lower respiratory tract, urinary tract, eyes and others.11
not meet the requirements of raw water but had fulfilled Therefore monitoring of the quality of refill drinking
the requirements for refill drinking water. water, especially monitoring of bacterial contamination
must be carried out continuously by owners of refill
Table 1also shows no Escherichia Coli bacteria
drinking water depot facilities themselves and by
were found but 2 other bacteria were found, namely
the local Health Service to provide guarantees for the
the bacteria Klebsiella pneumonia and Pseudomonas
community in obtaining drinking water that meets the
aerogenosa. These germs can cause infections in the
stipulated requirements.12
Table 1: Coliform Bacterial Contamination in Refill Drinking Water and Raw Water
Sample Code Index (MPN/100 ml) Qualified Number of Colonies Identification of Bacteria
D1 Raw water 4 Not 12 Pseudomonas aerogenosa
D1 Drinking water 0 Yes 0 Not cultured and identified
D2 Raw water 15 Not 52 Klebsiella pneumonia
D2 Drinking water 0 Yes 0 Not cultured and identified
D3 Raw water 460 Not 88 Pseudomonas aerogenosa
D3 Drinking water 28 Not 80 Pseudomonas aerogenosa
D4 Raw water 93 Not 130 Klebsiella pneumonia
D4 Drinking water 4 Not 6 Klebsiella pneumonia
D5 Raw water 8 Not 59 Klebsiella pneumonia
D5 Drinking water 7 Not 32 Klebsiella pneumonia
D6 Raw water 4 Not 15 Klebsiella pneumonia
D6 Drinking water 0 Yes 0 Not cultured and identified
DAMIU Sanitation Environmental: Table 2 shows the environmental sanitation in the aspect of location
at
6 drinking water depots shows that there are 2 depots that meet the requirements and 4 depots do not meet the
requirements namely D2, D3, D4, and D5. Also in the aspect of the building in 6 drinking water depots, all of them
did not meet the 100% requirement according to the Decree of the Minister of Industry and Trade of Republic of
Indonesia Number 651/MPP/Kep/10/2004.

Table 2: Environmental Sanitation of Refill Drinking Water Depots

Environment sanitation Qualified Frequency (n) Percentage (%)
Yes 2 33
Location
Not 4 67
Yes 0 0
Building
Not 6 100

Sanitation Equipment of DAMIU: Table 3 shows the sanitation equipment at 6 water depots have all fulfilled the
requirements according to the Decree of the Minister of Industry and Trade of Republic of Indonesia Number 651/
MPP/Kep/10/2004.The treatment of drinking water in refill drinking water depots is not entirely done automatically
so that it can affect the quality of the water produced, thus the quality still needs to be studied in order to safeguard
its water quality.13

Table 3: Sanitation Equipment in Refill Drinking Water Depots

Equipment for Sanitation Qualified Frequency (n) Percentage (%)
Made from food ingredients, corrosion Yes 6 100
resistant, does not react with chemicals Not 0 0
Yes 6 100
The tool used is still in use
Not 0 0
Material is not made of heavy metal that is Yes 6 100
soluble in water Not 0 0
DAMIU Worker Hygiene Overview: Based on Table 4, the criteria that are not met by all depots is using masks,
no workers use masks.

Table 4: Hygiene of Workers in Refill Water Depots

Worker Hygiene Qualified Frequency (n) Percentage (%)
Yes 6 100
Must be free from infectious diseases
Not 0 0
Free from wounds, ulcers, skin diseases, and Yes 6 100
other injuries Not 0 0
Yes 5 83.3
Wash hands before and after serving consumers
Not 1 16.7
At the time serving consumers do not eat, long Yes 6 100
nails, scratching and scratching ears/nose/teeth Not 0 0
Yes 6 100
Wear clean clothes
Not 0 0
Yes 0 0
Using a medical mask
Not 6 100

The use of masks during the production process will minimize contamination of processed water from workers.
Hygienic and sanitary behaviour needs to be done every time to serve consumers, including always washing hands
with soap and running water, each serving consumers to prevent pollution.14 Hands that are not clean can be a
source of contamination of pathogenic bacteria that can increase the risk of pollution. The use of personal protective
equipment such as gloves in work is also needed as a prevention of contamination.15 Workers who do not have
hygiene and healthy lifestyle such as not washing their hands and smoking while serving consumers can cause
contamination of drinking water.16 Therefore, it is better for refill drinking water depots to maintain sanitary hygiene
to avoid bacterial contamination. Places that are guaranteed sanitary hygiene clean and healthy workers,
recommended equipment is safe and raw water from clean water sources will ensure the quality of healthy and safe
water.17

Description of the DAMIU Processing Method: Table 5 shows there are 4 depots that use one method of drinking
water treatment that is using Reserve Osmosis (RO) and 2 depots using a combined processing method that is using
Ultraviolet (UV) and Reserve Osmosis (RO).

Table 5: Processing methods in Refill Drinking Water Depots

DAMIU Processing Method Frequency (n) Percentage (%)
Using Reserve Osmosis (RO) 4 66.7
Using UV + RO 2 33.3
The process of purifying water with Reserve Conclusion
Osmosis (RO) will produce water that is truly pure free
from the content of minerals and other toxic substances. The obtained results show that all raw water in the
In this process Reserve Osmosis (RO) there are stages depot did not meet the requirements and in refill
that must be considered, among others, the water source drinking water there were 3 depots that met the
of raw materials, the water treatment process, and the requirements. The types of bacteria in raw water and
type of Reserve Osmosis (RO).18 The processing of refill refill drinking water in drinking water depots are
drinking water using ultraviolet light is known to be able Klebsiellapneumoniae and Pseudomonas aerogenosa
to kill microorganisms because it has a lethal effect on bacteria. Environmental sanitation for drinking water
microorganisms.19 depots based on location aspects has fulfilled the
requirements, but in the building
aspects all depots do not meet the requirements. 1]. Available from http://jurnal.fk.unand.ac.id/
Sanitation of drinking water depot equipment indicates articles/vol_1no_3/129-133.pdf
that all drinking water depots have fulfilled the
5. Bambang AG, Fatimawali, Kojong NS.
requirements. Hygiene of drinking water depot workers
Analysis of Coliform Bacteria Contamination
shows that there are 5 depots with fulfilment of criteria
and Identification of Escherichia Coli in Water
84% and 1 depot with fulfilment of criteria 67%. There
Refill from Depots in Manado City. Pharmacy
are 2 drinking water depots use a combined method with
Scientific Journal. UNSRAT [Internet]. 2014.
UV and RO and 4 drinking water depots that use RO
[cited 2016 Dec 1]. Available from http://ejournal.
method only.
unsra t .a c .i d/ i nde x.php/ pha rm a c on/ a
rt i c l e / download/5450/4957
Acknowledgement
6. Unicef Indonesia. Clean Water, Sanitation and
The authors would like to thank to the participants, Hygiene [Internet]. 2012. [cited 2016 Dec 5].
BarrangLompo Island Health Center, Faculty of Available from http://www.unicef.org/indonesia/
Medicine, and Faculty of Public Health, Hasanuddin id/A8_-_B_Ringkasan_Kajian_Air_Bersih.pdf
University for unconditionally support.
7. Indirawati SM. Hygiene Analysis of Sanitation
Ethical Clearance: Taken from the committee and Quality of Refill Drinking Water Based on
Raw Water Source in Drinking Water Depots in
Source of Funding: Nil Medan City. Thesis. USU.2009.
Conflict of Interest: Nil 8. NovitaE. Factors Affecting the Quality of
Drinking Water Refill in Palembang City in 2004.
REFERENCES Thesis. University of Indonesia. 2004.

1. Apriliana E, Ramadhian MR, Gapila M. 9. Selintung M, Zubair A, Rakhman D. Study of

Bacteriological Quality of Refill Drinking Water Clean Water Supply Systems in Barrang Lompo
at Refill Drinking Water Depots in Bandar Island, Ujung Tanah District, Makassar
Lampung [Internet]. 2014 [cited 2016 Nov 28]. City.
Available from http://juke.kedokteran.unila.ac.id/ 2013. Journal of Civil Engineering. Hasanuddin
index.php/juke/article/download/401/402 University. [Internet]. 2013. [cited 2016
Dec
2. Parera MJ. Analysis of the Differences in the Test
5]. Available from http://repository.unhas.ac.id/
of Water Well Quality in the Madidir Ure Village
handle/123456789/9728
of Bitung City Based on Physical Parameters.
Thesis. Medical Faculty of the University of Sam 10. Nurmawati F, Mifbakhuddin, WardaniSR.
Ratulangi [Internet]. 2014 [cited 2016 Nov 28]. Relationship Between Individual Hygiene and
Available from http://ejournal.unsrat.ac.id/index. Sanitation Officers Depo Refill Drinking Water
php/ebiomedik/article/download/4584/4112 with Amount of Coliform Bacteria in Sendang
Mulyo Village, Semarang City. Essay. Faculty
3. Tirsa TS, Henry MF, Rahayu HA. Description of Public Health. Muhammadiyah University
of the Bacteriological and Chemical Quality of Semarang. Semarang. 2009.
the Water in the Langowan Unit of the Minahasa
Regency year, Sam Ratulangi University Public 11. Syahrurachman A. Textbook on Medical
Health Faculty. 2014. Microbiology, Ciputat, Tangerang, Binarupa
Aksara. 2010.
4. Wandrivel R, Suharti N, Lestari Y. Quality
of Produced Drinking Water Depots of Refill 12. Radji. Bacteriological Examination of Drinking
Drinking Water in Padang Bungus District Water Refills in Several Refill Drinking Water
Based on Microbiology Requirements. Andalas Depots in Lenteng Agung and Srengseng Sawah
Health Journal [Internet]. 2012. [cited 2016 Areas, South Jakarta. [Internet]. 2008. Journal
Dec of Pharmaceutical Sciences. [cited 2017 May
15]. Available from http://psr.ui.ac.id/index.php/
journal/article/download/3424/502
13. Athena, Sukar, Haryono. Content of Total Water Depot (DAMIU) in 73 Cimareme District,
Bacteria of Coli and Escherichia Coli/Fecal Coli West Bandung Regency. Proceedings of the
Drinking Water from Refill Drinking Water 2013 National Seminar on Natural Resource
Depots in Jakarta, Tangerang and Bekasi. Health Management and Environment. [Internet]. 2013.
Ecology Research Center, Research and [cited 2017May 15]. Available from http://eprints.
Development Agency. [Internet]. 2004. [cited undip.ac.id/40580/1/010-Ari_Khoeriyah.pdf
2016 Nov 28]. Available from
17. Kemenkes RI. Guidelines for Implementing
http://ejournal.litbang.depkes.
Sanitation Depot Drinking Water Hygiene in
go.id/index.php/BPK/article/viewFile/1216/144
Jakarta. [Internet]. 2010. [cited 2016Nov 28].
14. Permenkes. Nomor 43 Tahun 2014. About Available from http://kin.perpusnas.go.id/
Sanitation Depot for Drinking Water. Jakarta. DisplayData.aspx?pId = 9730 & pRegionCode =
[Internet]. 2014. [cited 2017 May 15]. Available PKSJOG & pClientId = 145
from
18. Imbo N. Study of the Quality and Quality of
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Refill Drinking Water (DAMIU) in Terms of
regulasi/permen-kesehatan-nomor-43-tahun-
the Parameters of Fluorine (F) and Iron (Fe)
2014-tentang-higiene-sanitasi-depot-airinum.pdf
in Drinking Water Deposits in the District of
15. Cahyaningsih CT, Kushadiwijaya H, Tholib A. Borkanaya, Makassar City. Essay. Hasanuddin
Relationship between Sanitation and Food University. 2011.
Handler Hygiene with Bacteriological Quality of
19. Arie IS, Imam S. The Use of Drinking Water
Tableware at Food Stalls. Journal of Public
Sterilization Tools By Using Ultra Violet
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(UV) Lights In Household Stairs. Ruwa Jurai
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index.php/BKM/article/view/178/102
16. Khoeriyah. Aspects of Bacteriological Quality
and Physical Sanitation Hygiene Refill
Drinking
DOI Number: 10.5958/0976-5506.2019.01714.5

Relationship between Work Posture and Musculoskeletal

Disorders (Msds) at Processing Workers in PtToarco Jaya,
Rantepao City year 2017

Januarty Triani Rimba1, Furqaan Naiem1, Muhammad Rum Rahim1

1
Department of Work Safety and Health, Faculty of Public Health, Hasanuddin University

ABSTRACT
Musculoskeletal Disorders (MSDs) are one of the problems that are often experienced by workers in both
the informal sector and the formal sector. PT Toarco Jaya Processing worker is an industry that engaged in
Arabica coffee production where there are activities that are quite high, monotonous and repetitive. This
can cause workers to experience skeletal muscle disorders that can reduce work productivity. This study
aims to determine the relationship of work posture with Musculoskeletal Disorders (MSDs) disorders in PT
Toarco Jaya processing workers in the city of Rantepao in 2017. This type of research was observational
analytic with a cross sectional study approach. Data collection is conducted against 57 workers by
exhaustive sampling in March 2017. Primary data collection was obtained from interviews using
questionnaires, Nordic Body Map Questionnaire, Rapid Entire Body Assessment, microtoise, scales and
cameras. Data analysis was performed using univariate analysis, namely frequency distribution and
percentage of each variable and bivariate analysis was performed on two variables to identify relationships
using the chi-square test. The results of this study indicate that there is a relationship between work posture
and MSDs complaints with a p value (0.002), there is a relationship between age, nutritional status, and
work period with complaints of MSDs with a value of p (0.005), p (0.030), p (0.031) < α (0.05). It is best
for the company management to provide training on work posture at work. Others factors such as workload
and environmental factors are recommended in future study.

Keywords: Work Posture; Musculoskeletal Disorders; Processing

Workers
Introduction the muscles of the neck, shoulders, arms, hands, fingers,
back, waist, and lower muscles. 3 From various types of
As a developing country, Indonesia needs healthy,
research, it can be seen that the complaints of diseases
efficient and productive human resources to support
that are often suffered by workers are work related
national development. Besides that labor is an element
musculoskeletal disorders, one of which is influenced by
that is directly confronted with various consequences of
the existence of a work position. The work method will
technological advances in industry, so it is only natural
directly or indirectly affect the muscles involved and can
for them to be given health care protection and
cause muscoleskeletas disorders with complaints of pain
development towards welfare or national guarantees.1
in the neck, back, lower back and other complaints.4
Based on data from the International Labor Organization
(ILO) in 2013, every 15 seconds one worker dies from a In a study conducted on paving workers in
work accident and 160 workers experience work-related CV SumberGalian, Makassar, showed that of 85
illness.2 respondents there were 52 respondents who experienced
severe disorder Muscoleskeletas disorder and 32 other
The factors that cause musculoskeletal complaints respondents had mild disorder muscoleskeletas disorder,
are excessive muscle stretching, languishing activity, this indicates that there are still many workers who
unnatural work attitude, secondary causes and suffer from muscoleskeletas disorder specifically in
combination causes.3 Studies of musculoskeletal in the city of Makassar.5 Based on research conducted on
various types of industries have been carried out and Fumiture workers in Benda Kota Tangerang District,
studies have shown that muscle parts that are often showed that there were 27 workers (81.8%) aged ≥
complained about are skeletal muscle which includes 30
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years who had musculoskeletal disorder and as many Method of Collecting Data: The data on complaints of
as 22 workers (45.8%) aged <30 years also experienced Musculoskeletal Disorders (MSDs) were obtained using
musculoskeletal disorder. The results of bivariate
statistical tests showed that there was a significant
relationship between age and musculoskeletal disorder.
According to Suma’mur (2009) in a week people can
only work well for 40-50 hours. More than that negative
tendencies arise.6

Body mass index (BMI) can also be used as an

indicator of the condition of worker nutrition according
to Zulfiqor (2010) who conducted research on
fabrication workers at PT.7 Caterpillar Indonesia,
someone who is overweight will try to support the
weight from the front by contracting the lower back
muscles. And if this continues, it will cause pressure on
the spinal cord pads which results in fatigue and muscle
pain. Based on the results, it was obtained workers who
had an index of body obesity period of 13 workers
(17.3%) and workers with a normal body mass index of
32 workers (42.7%). The test results showed that most
workers had a normal BMI and experienced
complaints of mild MSDs, namely 26 workers. This is
not in line with the research of Karuniasih (2009) which
examined 52 bus travel drivers, which amounted to
90.4% of MSDs complaints experienced by bus drivers
who had excessive body mass index (overweight) or
obesity.8

Work posture and work position that are not

ergonomic have an impact on decreasing work
productivity and work performance which can lead to
work accidents, besides that it can also affect workers’
health levels, one of which is muscle and joint
complaints or musculoskeletal complaints. Based on the
description of the background above, the authors are
interested in conducting research on the relationship of
work posture with disorders of Musculoskeletal
Disorders (MSDs) in PT workers,Toarco Jaya, Rantepao
City.

Methodology

This study used observational analytic method. A

cross sectional approach was used to identify the
relationship of work posture variables with
musculoskeletal disorder (MSDs). The location of the
research was carried out at PT. Toarco Jaya, the city of
Rantepao.The population used as samples in the study
were 57 processing workers at PT Toarco Jaya, Rantepao
City.
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the Nordic Body Map questionnaire. The data on work
posture is obtained by calculating the risk of skeletal
muscle pain in certain body parts (neck, spine, upper &
lower arms, wrists) using the REPR (Rapid Entire Body
Assessment) sheet. The data on the Body Mass Index
obtained through direct measurement of body weight
and height of workers using a weight scale and
microtoice role and then calculated using the BMI
formula.

Data Processing: Processing and data analysis

techniques were carried out by Chi Square statistical
tests and using the SPSS program.

Data Analysis: Univariate analysis was performed on

each variable from the results of this study to see the
frequency and percentage distribution, which included
work attitudes, age, length of work, length of service,
nutritional status, musculoskeletal disorder (MSDs).
Bivariate analysis is done to prove the hypothesis with
the chi-square test where the variable work attitudes,
age, work status of nutritional status (BMI) and years of
service with MSDs complaints in this study.

Result and Discussion

Retrieval of respondents’ research data was

conducted in March 2017 with 57 Processing workers.
This study gains the permission of the Manager of PT
Toarco Jaya and the head of Processing. Interviews
were conducted using questionnaires and the Nordic
Body Map Questionnaire. Then, measurements of
workers’ height were carried out using microtoise and
for measuring body weight using weight scales. The data
obtained is then processed using the SPSS computer
program.

The characteristics of the respondents show

majority of the respondents are from age group of 35-
44 and 45-54 contribute by 35% and 33% respondents
respectively. Next, most of the respondents about 63.2%
have working period between 3 to 10 years. For nutrition
status, majority about 40.4% of the respondents are
under fat categories where thin and normal categories
contribute by equal percentage which is 28.1% each.

Distribution of Respondents based on

Musculoskeletal Disorders Complaints (MSDs): In
this study, complaints of Musculoskeletal Disorders
(MSDs) in processing part workers were grouped into
two, namely workers who experienced MSDs
complaints (80.7%)
and workers who did not experience MSDs complaints namely high risk (aged ≥ 30 years) and low risk (aged
(19.3%). The highest reported body parts for MSDs are <30 years). High risk category has 77.2% of the
neck, waist, left ankle, right ankle, right shoulder, left respondents and a low risk category has 22.8% of the
shoulder and back contribute by 45.6%, 42.1%, 38.5%, respondents.
38.5%, 36.8%, 33.3% and 26.3% respectively.
The nutritional status has two categories where the
Distribution of Respondents based on Work Posture, abnormal nutritional status is BMI> 25 or <18.5 and
Age, Nutritional status and Working period: High- for the category of normal nutritional status is BMI
risk workers are who have 8-15 Rapid Entire Body ranged from 18.5-25. Table 1 shows that 71.9% of the
Assessment (REBA) scores or action levels 3 and 4. For respondents are under abnormal nutritional status and
low-risk work postures, they have a REBA score of 1-7 the respondents under normal nutritional status are
or level 0, 1, and 2. Table 1 shows that the work posture 28.1%. Working period is grouped into two categories
on processing workers who have a high risk are 73.7%. where the respondents who have worked for ≥ 5 years
The number of workers with a low risk work posture and working period of <5 years. The working period of
is 26.3%. The age of respondents into two respondents with the category ≥ 5 years is 47.4%
categories, and
category which is <5 years is 52.6%.

Table 1: Distribution of Respondents based on Work Posture, Age, Nutritional status and Working period
Items Categories Frequency (n) Percentage (%)
High Risk (8-15 REBA) 42 73.7
Work posture
Low Risk (1-7 REBA) 15 26.3
High Risk (More than 30 years old) 44 77.2
Age
Low Risk (Less than 30 years old) 13 22.8
Normal 16 28.1
Nutritional status
Not Normal 41 71.9
Old (More than 5 years) 27 47.4
Working period
New (Less than 5 years) 30 52.6
Relationship between Complaints on Musculoskeletal service that did not experience MSDs complaints.
Disorders (MSDs) with Work Posture, Working The chi-square
Period, Age and Nutritional Status: Table 2 shows
there are 90.5% of the respondent experienced
musculoskeletal disorders with high risk work posture
and 53.3% of the respondent experienced
musculoskeletal disorders with low risk work posture.
Besides that, there are 46.7% and 9.5% of the
respondent did not experienced low risk and high risk
respectively. The chi-square test obtained p = 0.002 (p =
<0.05), so that H0 is accepted and Ha is rejected so that
it can be interpreted that there is a relationship between
work posture and complaints of musculoskeletal
disorders (MSDs) in processing workers PT Toarco Jaya
In 2017.

Table 2 shows there are 92.6% of the respondents

are from long service life which is more than 5 years
and about 7.0.0% are from new work a period which is
less than 5 years. Furthermore, respondents who did not
experience MSDs complaints with a long working
period about 7.4% and 30.0% with new years of
test obtained the value of p = 0.031 (p <0.05) means
that H0 is rejected and Ha is accepted, so that it can be
interpreted that there is a relationship between work
period and MSDs complaint on processing workers PT
Toarco Jaya Kota RantepaoTahun 2017.

Table 2 shows the high risk age that experienced

MSDs complaints are about 88.9% and high risk age
that experienced MSDs complaints are about 53.8%.
Then, respondents who did not experience MSDs with a
high risk age category is about 11.4% and a low risk age
category is about 46.2%. The chi-square test obtained
the value of p = 0.005 (p <0.05) means that H0 is
rejected and Ha is accepted, so that it can be interpreted
that there is a relationship between age and MSDs
complaints in
2017 PT Toraco Jaya processing workers.

Table 2 shows the respondents who experienced

complaints of MSDs with abnormal nutritional status
were 36 respondents are 87.8% and respondents who
experienced complaints of MSDs with normal nutritional
status are 62.5%. Respondents who did not
experience
complaints of MSDs with abnormal nutritional status and Ha is accepted, so it can be interpreted that there
are 12.2%, while respondents with normal nutritional is a relationship between nutritional status and MSDs
status are 37.5%. The chi-square test obtained the complaints to processing workers PT Toarco Jaya,
value of p = 0.030 (p <0.05) means that H0 is Rantepao, Tahun 2017.
rejected
Table 2: Relationship between Complaints on Musculoskeletal Disorders (MSDs) with Work
Posture, Working Period, Age and Nutritional Status

Relationship between Complaints on Musculoskeletal Complaints of MSDs Statistical test

Disorders (MSDs) No (%) Yes (%) results (P value)
Low Risk (1-7 REBA) 46.7 53.3
Work Posture 0.002
High Risk (8-15 REBA) 9.5 90.5
New (More than 5 years) 30.0 70.0
Working Period 0.031
Old (Less than 5 years) 7.4 92.6
Low Risk (Less than 30 years old) 46.2 53.8
Age 0.005
High Risk (More than 30 years old) 11.4 88.9
Normal 37.5 62.5
Nutritional Status 0.030
Not Normal 12.2 87.8
The results of this study are consistent with the systems.1 This study is in line with Tarwaka (2010)
research conducted by Suwanto, J (2016) that the results which states that workers who than 35 years old have a
of statistical tests using the Spearman Rho test with a small risk of experiencing musculoskeletal complaints.3
significant level (α≤0.05) obtained a significance value These complaints occur because in general, skeletal
(p = 0.001) with a moderate relationship (r = 0.551) muscle complaints begin to be felt in working age,
hence there is a significant relationship between the which is 25-65 years. Nusa, et al (2013) showed that
risk of work posture and the risk of musculoskeletal there was a significant relationship between age with
complaints.9 Meanwhile, according to Nurhayati musculoskeletal complaints with a value of p = 0.003 (p
(2013), the results of statistical tests on the relationship <0.05) and the closeness value of the relationship was
between work posture and musculoskeletal complaints positive, namely the higher the age the higher the risk of
with a significance value of 0,000 p-value <0.05, a musculoskeletal complaints.13
correlation strength value of 0.657 (strong) and a
positive correlation means that there is a strong and very This is consistent with Puput’s 2015 study which
significant relationship between postures work with showed that body mass index (BMI) had a significant
musculoskeletal complaints. 10 relationship with musculoskeletal complaints.14
According to Supariasa (2002), the Body Mass Index
Boshuizen et al in Margarini (2014), states that (BMI) or Body Mass Index (BMI) is a simple tool or
someone who works more than 5 years increases the risk way to monitor the nutritional status of adults, especially
of back pain compared to less than 5 years of exposure.11 those associated with underweight and overweight.15
This can occur because the loading of the spine for a
The association of BMI with MSDs is the more fat
long time can cause the disc cavity to constrict a
permanently and also result in spinal degeneration which person is, the greater the risk of experiencing MSDs.
can cause chronic lower back pain. The same is true of
Aisyah (2014), in lifting workers about the relationship
between individual characteristics and work position Conclusion
with musculoskeletal complaints in lift-up workers at Based on the results of research on the relationship
PT.12
of work posture with complaints of musculoskeletal
AJG Gresik is one of them concerning working period
disorders in PT Toarco Jaya Processing workers in the
which shows that there is a relationship between years of
city of Rantepao in 2017, the musculoskeletal Disorders
service and musculoskeletal complaints.
(MSDs) complaints on processing workers are more
Age is identical to the level of work ability by than workers who do not experience MSDs complaints.
changes in body tools, cardiovascular and hormonal Work posture, Working period, Age and Nutritional
status
are related to complaints of Musculoskeletal Disorders Scientific Thesis. State Islamic University Syarif
(MSDs) in PT Toarco Jaya processing workers in the Hidayatullah Jakarta. 2010.
city of Rantepao in 2017.
8. Karuniasih. Review of physiology and complaints
about the impact of musculoskeletal disorders on
Acknowledgement the driver of the Trans-Jakarta Travel X-Bandung
travel destination. Journal. Jakarkat: Indonesian
The authors would like to thank to the participants
University Community Health Faculty. 2009.
at PT Toarco Jaya, Rantepao City.and Faculty of Public
Health, Hasanuddin University for unconditionally 9. Suwanto J. Relationships between Risks of
support. Posture Work with Risk of Complaints on
Mollusculoskeletal Workers in the Cutting Section
Ethical Clearance: Taken from the committee of Iron in the Industrial Center in the Padas
Industry in Klaten. Thesis. Health Sciences
Source of Funding: Nil
Faculty. Muhammadiyah University Surakarta.
Conflict of Interest: Nil 2016.
10. Nurhayati H. Relationship between Posture Work
REFERENCES with Complaints Muskuloskleetal on Work Press
Dryer UD. Abioso, Boyolali. Scientific Thesis.
1. Suma’mur PK. Company Hygiene and
Surakarta: UNS. 2013.
Work
Safety. Printing 13. Haji Masagung: Jakarta. 1996. 11. Margarini AF. Relation of Factors to
Characteristics of Individuals, Economical Factors
2. ILO. The Prevention of Occupational Diseases. with Complaints on Subjective Musculoskeletal
[Internet]. 2013. [cited 2015 Oct 25]. Available Disorders (MSDs) in Construction Workers of PT.
from www.ilo.org/wcmsp5/groups/public/ X. Thesis.Surabaya: Faculty of Health, University
wcms_204755.pdf of North Carolina. 2014.

3. Tarwaka. Industrial Ergonomics, Knowledge 12. Aisyah F. Relationship Characteristics of

Fundamentals and Applications at Work. Individuals and Position of Work with Complaints
Publisher: Harapan Press Solo. 2010. of Musculoskeletal Disorders in Cluster Workers
4. Fatimah T. Pain in the Back of the Stitching in Warehousing of PT AJG Gresik 2014. Thesis.
Surabaya: Faculty of Health Community of the
Workers Section at PT Intigarmindo Persada
University of North Carolina. 2014.
Jakarta. Thesis. Jakarta: Veterans National
Development University. 2011. 13. Nusa Y, Joseph WB, Lampus BS. Relationships
between Tribes, Duration of Work, and Shaking
5. Cindyastira D. Relationship between Circulation
with Complaints on the Musculoskeletal System
with Complaints on Musculoskeletas Disorder
at Manado-Langowan Route Bus Driver at
in Block Paving Workers at CV Sumber Galian,
Karombasan Terminal. Journal. Community
Makassar City. Makassar Journal: Faculty of Health Faculty, Samrat University repeated. 2013.
Health Community of Hasanuddin University.
2014. 14. Puput NF, Catur Y. Secondary Factors Associated
With Complaints of Mollusculoskeletal Laundry
6. Suma’mur PK. Corporate Hygiene and Workers in Muktiharjo Kidul Village Semarang.
Occupational Health (Hiperkes). Sagung Seto: Journal of Dian Nuswantoro University Health
Jakarta. 2009. Faculty. 2015.
7. Zulfiqor MT. Related Factors with Complaints of 15. Supariasa, I.D.N. Nutritional Status Assessment.
Mollusculoskeletal Disorders in Welder in Parts Jakarta: ECG Medical Book. 2002.
Fabrication of PT. Caterpillar Indonesia in
2010.
DOI Number: 10.5958/0976-5506.2019.01715.7

A Study on Frequency of 12-23 Months of Children Visits to

Integrated Service Post (Posyandu) 3 Months in a Row against
Developments in the Work Areas, Makassar City

Khalis Muliamar1, Djunaedi M. Dachlan1, Burhanuddin Bahar1

1
Nutrition Study Program, Faculty of Public Health, Hasanuddin University, Makassar

ABSTRACT
Based on data from the National Central Statistics Agency currently there are an estimated 351,000 children
with special needs under the age of five. This study aims to describe the frequency of visits between 12-
23 months to Posyandu (Integrated Service Post) for 3 consecutive months on the development of baduta
(children under two) in the Working Area of the Puskesmas, Makassar City. The type of study method used
is descriptive survey research. The sampling method in this study was purposive sampling with
predetermined criteria. The sample in this study is the age of 12-23 months with 35 badutas taken from 9
posyandu. Data was taken using the family characteristic questionnaire and the Pre Development Screening
Questionnaire (KPSP) to measure the development of baduta. The collected data is processed using the
SPSS program and presented in table form along with narration. The results showed that out of a total of 35
people who visited the posyandu 3 months in a row there were 34 baduta (97.1%) with normal
development and the rest with deviant development (2.9%). When tested for development using a 15-
month KPSP, the person could not carry out 5 tests out of a total of 10 tests in the 15-month KPSP. These 5
tests are rough movements. Based on the results of the study, it is suggested that the puskesmas conduct
development checks at all posyandu so that children’s development can be monitored.

Keywords: Posyandu (Integrated Service Post); Developments; Work

Areas
Introduction and social economy.3 The results of the 2007 Basic
Health Research (Riskesdas) showed that Posyandu was
The national development goals listed in the concept
the most visited place for underfive weighing, which was
of the 2015-2019 National Long Term Development
78.3%; toddlers weighed regularly (4 times or more),
Plan (RPJMN) are one of which is to improve the
weighed 1-3 times and which were never weighed
quality of human resources (HR). Efforts to improve the
consecutively were 45.4%, 29.1% and 25.5%.4
quality of human resources begin with the process of
developing children from conception to young The results of Riskesdas in 2010 showed that the
adulthood. Posyandu is a form of community higher the age of the child, the lower the scope of the
participation in the health sector that is managed by weighing was carried out at the posyandu (≥ 4 times
cadres targeting the entire community. Posyandu is one over the past six months). The percentage of weighing
of the health services in the village to make it easier for children under the age of sex is not different, but
people to know or check health, especially for pregnant according to the place of residence in urban areas the
women and toddler.1 One of the posyandu’s objectives is tendency is to weigh their children in the posyandu
to monitor improvement in nutritional status toddlers rather than in rural areas.5
and pregnant women. However, public awareness of
health care, especially toddlers, is still lacking, so there Riskesdas 2013 shows that monitoring the growth
are still toddlers with impaired growth development.2 of toddlers carried out every month shows that the
percentage of infants aged 6–59 months who have never
The active visit of mothers to bring their children been weighed in the past six months tends to increase
to the posyandu is influenced by several factors such as from 25.5% (2007), 23.8 percent (2010), to 34, 3%
age, education, employment, access to health (2013).6 What are the impacts on toddlers, if mothers of
services,
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children under five are not active in Posyandu activities, 12-23 months who were enrolled at the posyandu who
among others, do not get health counselling about the visited the Posyandu for 3 consecutive months. Samples
growth of normal toddlers, do not get vitamin A for eye will be included in the study if they meet the criteria
health, mothers of children under five do not know the such as mother, who have KMS toddlers, have babies
growth of body weight for months.4 aged 12-23 months, children visited Posyandu in the last
3 months, children no hospitalized for the past 3 months
In Indonesia, data on deviations in pre-school child and never sick for more than 7 days.
development have not been recorded accurately and
specifically, but UNESCO can estimate children who Data Collection: The data obtained directly from
have a deviant tendency to reach at least 10% and this respondents through a questionnaire, which is the Pre
can be a strong reference. Meanwhile, based on data Development Screening Questionnaire (KPSP) to see
from the National Central Statistics Agency currently the development according to the age of the baby which
there are an estimated 351,000 children with special included subtle motion, rough motion, speech and
needs under the age of five. 7 Several studies on the language, socialization and independence. The latest
relationship between language development and family secondary data is obtained by referring at the results of
socio-economic status show that children from poor the toddler weighing record and the posyandu register
families experience delays in the development of their book.
language compared to children from better families.8 Data Processing and Analysis: The collected data are
In Indonesia, it is famous for the term children processed using the SPSS program through Univariate
under three years old. Even though physical Analysis.
development (especially feet) at this age is not the
main thing, children in toddlers at stage 1 like to walk, Result and Discussion
climb or climb something. At this stage, it is very
The environmental condition of the Antara Health
important for parents to be the main safeguards. 9
Center is an urban development area, a dense residential
Therefore, this study is identifying the Frequency of
environment, some areas are still slums, mainly on the
Visits from 12-23 Months to 3-Month Consecutive
outskirts and some areas are lowlands, allowing floods
Posyandu on Developments in the Work Areas of
to occur. Community behaviour still does not have
Puskesmas, Makassar City.
clean culture; the personal hygiene of children is still
low, consumption of fast food, and smoking. The work
Methodology program of the Antara Health Center for improving
community nutrition includes the provision of vitamin A
The type of study method used is descriptive survey capsules, Fe tablets for pregnant women, supplementary
method which is to find out the description of the feeding to infants and toddlers. Health promotion
frequency of posyandu visits in 3 consecutive months to includes alert villages, PHBS coaching/counselling,
the growth of toddlers aged 12-23 months in the development of health posts (Poskestren and Posyandu),
working area of the Puskesmas, Makassar City. This public health counselling, occupational health efforts
study was conducted in the Community Health Center (UKK).
Working Area between March-April 2017.
Table 1 shows there are a total of 133 physical
Population and Sample: The population in this study targets in 9 PosyandupuskesmasAntara. The population
were all children aged 12-23 months. The sampling is 58 baduta who had visited in April. While baduta
technique in this study was purposive sampling. The who visited 3 months in a row about 36 baduta and the
samples in the study were mothers of the children aged sample considered in this study were 35 baduta, which
meet the sample criteria.

Table 1: Target Data and Posyandu Visits 3 consecutive months in the working area of the health
center between 2017

Visited
Posyandu Baduta Sample
Feb Mar Apr 3 Con. months
Kantisang 17 14 13 2 1 1
Antara 12 11 8 8 6 5
Hamzy RW 3 12 11 9 7 4 4
Conted…
Hamzy RW 2 19 16 10 7 4 4
AsalMula 12 11 10 8 5 5
Bontosugi 33 25 22 9 4 4
KeraRamsis 8 7 7 5 3 3
Hartaco Jaya 12 7 7 6 4 4
Immim 8 8 8 6 5 5
Total 133 110 94 58 36 35

Table 2 shows there are 34 baduta with normal development and 1 baduta with development deviate. Baduta
with this deviant development is 16 months old and female. When tested for development using a 15-month KPSP,
the person could not carry out 5 tests out of a total of 10 tests in the 15-month KPSP. These 5 tests are rough
movements. The cause of the baduta was not able to do any rough motion tests because the growth of baduta legs
was hampered, making it difficult to stand. Based on the KIA 2016 book, the stimulation parents can do to
overcome this is by slowly training children to stand up and walk by holding on, and teach children to walk on the
steps/stairs.10 In addition, to monitor the progress of the health center the health center should do examination of
developments in the posyandu so that the possibility of developmental irregularities can be prevented.

Table 2: Distribution of Baduta KPSP Score Categories

KPSP Score Baduta Age Category

Total
Category 12-14 months 15-17 months 18-20 months 21-23 months
Normal (%) 22.9 34.3 14.3 25.7 97.1
Deviate (%) 0.0 2.9 0.0 0.0 2.9

Table 3 shows there is 1 baduta with a percentage of fine motion KPSP score of 67% which is in the age of 12-
14 months. Baduta is 14 months old. Of the 3 subtle motion test questions at the 12-month KPSP, there was 1 test
question that could not be implemented by the person. The baduta fail to grab the pencil tightly and can be easily
taken away. This can be caused by a lack of developmental stimulation by parents. Based on the 2016 KIA book,
the stimulation that parents can give is to teach children to scribble pencils on paper, hold their own cups, and hold
small objects.10

Table 3: Distribution of Percentage of Subtle Motion KPSP Score

Percentage of Subtle Baduta Age Category

Total
Motion KPSP Score 12-14 months 15-17 months 18-20 months 21-23 months
67 % 1 0 0 0 1
100 % 7 13 5 9 34

Table 4 shows Bbaduta with the percentage of KPSP score of 80% of rough motion could not carry out 1 KPSP
test of gross motion from a total of 5 gross motion test questions in the 15-month KPSP. Baduta is 17 months, 15
months and 16 months old. The 17-month-old and 16 months old baduta fail to bend to pick up the toys without
holding or touching the floor. When he wants to take the toy he immediately sits down and does not want to stand
up again. The 15-month-old baduta cannot walk along the room without falling or staggering. The stimulation that
can be given by parents based on the 2016 KIA book to optimize the development of the rough movements is such
as teaching children to walk along a room or staircase and teaching children to move freely in supervision.10
Table 4: Distribution of Percentage of Gross Motion KPSP Scores

Percentage of Gross Baduta Age Category (Months)

Total
Motion KPSP Score 12-14 15-17 18-20 21-23
0% 0 1 0 0 1
80 % 0 3 0 0 3
100 % 8 9 5 9 31

Table 5 shows there is 1 baduta with the percentage of KPSP scores speaking and language 0% that is at the
age of 15-17 months. Baduta is 15 months old. The Baduta is 15 months old and cannot carry out a speech and
language test from a total of 1 question. At the time of the test the baduta was not able to say the words. In other
words the baduta has a delay in speaking. Possible causes are lack of speech and language stimulation by parents.
The stimulation that can be given by parents based on the 2016 KIA book, among others, invites simple words such
as “ma-ma” and teaches to mention parts of his body.10

Table 5: Distribution of Percentage of Talk and Language KPSP Scores

Percentage of Talk and Baduta Age Category (Months)

Total
Language KPSP Scores 12-14 15-17 18-20 21-23
0% 0 1 0 0 1
100 % 8 12 5 9 34

Table 6 shows the distribution of Percentage of KPSP Scores on Socialization and Independence. Based on the
percentage of KPSP scores on socialization and independence there are 5 baduta with the percentage of KPSP score
on socialization and independence of 50%, which is in the age of 12-14 months. The Baduta was unable to carry out
1 test out of a total of 2 tests of socialization and independence in the 12-month KPSP. Baduta is aged 13 months (4
baduta) and 14 months. When tested 3 children baduta did not look for and expect researchers to reappear, but felt
afraid and some were shy and some were crying out of fear. The other 2 baduta did not show a shy attitude at all,
even feeling afraid. Baduta at that age should meet fear and shame when meeting new people. The stimulation that
parents can provide to overcome these problems is based on the 2016 KIA book, namely by introducing to family
members, invite to play with friends.10

Table 6: Distribution of Percentage of KPSP Scores on Socialization and Independence

Percentage of KPSP Scores on Baduta Age Category (Months)

Total
Socialization and Independence 12-14 15-17 18-20 21-23
50 % 5 0 0 0 5
100 % 3 13 5 9 30
Bebgei (2000) states that stimulation is less likely their abilities.7 Stimulation activities include various
to experience delays in development and where children activities to stimulate child development such as
are fostered with good stimulation by providing various exercise, speech, thinking, independence and getting
aspects of stimulation needed by children, namely along.7 Also, parents are the main cause of problems
rough motion, subtle movements, language and speech, arising from poor child stimulation.12
socialization and independence. 11, 12 According to
Hurlock (1994) argues that a stimulating environment Jafri and IsnaOvari’s study (2015) showed that the
is one of the factors driving children’s development.13 development of socialization before and after giving
A stimulating environment encourages good physical stimulation of socialization to the age group with poor
and mental development, while a non-stimulating categories increases from 52.2% to 87.0% for 36–47
environment causes the development of children below months of age, 48.1% to 55.6% for 48–59 months of age
and 46.7% to 86.7% age 60–71 months of age.
Social personal development is strongly influenced 1. Sumirat, Widhi, Isti W. Relationship between the
by the environment and interactions between children Activities of Culture and the Activities of
and parents/other adults.12 Child development will be Social
optimal if social interactions are sought according to
the needs of children at various stages of development.
According to Bebgei (2000) states that of 49
children
4.08% of children experience delays in development
of poor stimulation, namely children who received less
attention from his parents while 32.65%, children with
developmental interpretations doubted, among others,
with sufficient stimulation.11, 12

Conclusion

Based on the results of this study, the conclusion is

most of the baduta are born with normal body weight.
Most of the baduta who were sampled were given
exclusive breastfeeding by their mothers. The type of
MP-ASI given to all baduta is MP-ASI mixed (factory
and local). All nurses give birth at health services and
are assisted by health workers. There are 1 baduta that
has a deviant development. There is 1 baduta with a
percentage of subtle motion KPSP score 67% There is 1
baduta with the percentage of KPSP score of roughly
0% and 3 baduta movements with the percentage of
KPSP score moving roughly 80%. There is 1 baduta
with the percentage of KPSP score speaking and
language 0%. There are 5 baduta with a percentage of
KPSP score of
50% socialization and independence.It is recommended
that the Puskesmas conduct development checks at all
posyandu each month so that child development can
be monitored and the possibility of developmental
irregularities can be prevented. Parents must be
diligent in providing stimulation to the clown so that
developmental irregularities can be prevented.

Acknowledgement

The authors would like to thank to the participants

and Faculty of Public Health, Hasanuddin University for
unconditionally support.

Ethical Clearance: Taken from the committee

Source of Funding: Nil

Conflict of Interest: Nil

REFERENCES
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2. Sugiyarti. Compliance with Visit Posyand
and Gizi Status Balita at Posyandu
Karangbendoanguntapan, Bantul, Yogyakarta.
JNKI. 2014;2(3):141-146.
3. Maulana, A. Relationship between the Activity
of Culture in Politics and the Decrease in the
Number of Balita Bawah Garis Merah (BGM)
in the Village of Suko, West Java, West Java
Regency. Thesis. Jember University Nursing
Study Program. 2013.
4. Republic of Indonesia Ministry of Health. Health
System Research Bulletin. Surabaya: Bakti
Husada. 2007.
5. Republic of Indonesia Ministry of Health.
Indonesian Basic Health Research (Riskesdas)
2010. The Indonesian Ministry of Health’s
Research and Health Development Agency. 2010.
6. RI Ministry of Health. Basic Health Research.
Republic of Indonesia Ministry of Health
Research and Health Development. 2013.
7. Erviyanti, E. Relationship between Gizid Status
and Development of Pre-School Children in TK/
PAUD Kelubuk Buaya Sub-District, Koto Tangah
District, Padang City in 2015. Thesis. Andalas
University. 2015.
8. Soetjiningsih, Ranuh. Growing Flower Children
and Teenagers. Editions - 1. Jakarta: CV.
SagungSeto. 2014.
9. Soetjningsih. Child Growth. Jakarta: EGC.2005.
10. RI Ministry of Health. Mother and Child Health
Book. Jakarta: Ministry of Health and JICA
(Japan International Cooperation Agency). 2016.
11. Bebgei. Growing Flower Babies. Less Moon
on
2-6 Months. Semarang: FK. UNDIP. 2000.
12. Diana, Fivi M. Toddler Child Development
Monitoring. Journal of Public Health. 2010;4(2).
13. Elizabeth H. Child development. Jakarta:
Erlangga. 1998.
14. JafriY, Isna O. Relationship between Providing
Stimulation of Socialization with Socialization
Development in Children of 3-6 Years of Age at
the Posyandu of the District of North Jakarta City
of 2015. In the Study Program of Nursing School,
University of Singapore. 2015.
DOI Number: 10.5958/0976-5506.2019.01716.9

Analysis of Ability to Pay National Health Insurance

Contributions to Communities on Lakkang Island, Makassar
City in 2017

Andi Sahriana1, Dian Saputra Marzuki1, Muhammad Yusri Abadi1

1
Department of Administration & Health Policy, Faculty of Community Health, University of Hasanuddin,
Makassar, Indonesia

ABSTRACT
This study aimed to analyse the ability to pay National Health Insurance (NHI) contributions by the
community in the Lakkang Island of Makassar City. The type of research used is quantitative research with
a descriptive survey approach. The population in the study was 121 families who had not participated in the
NHI program on Lakkang Island. Saturated sampling method is used to obtain a sample of 95 families.
Data collection was carried out by direct interviews with the people of Lakkang Island based on the
questionnaire and the data analyzed using univariate analysis. The results showed that the ability to pay
ATP 1 of the respondents was in the capable category, which was 61.1% with an average of IDR 90,440
per month, for non-food ATP 2 category, it was 62.1% with an average amounting to IDR23,544 per
month. Non-essential is in the capable category, which is 51.6% with an average of IDR26,536 per month.

Keywords: Lakkang Island, NHI, ability to pay and

ATP.
Introduction Community participation in the NHI program can be
seen from the ability and willingness to pay
The development of health insurance in Indonesia contributions. Research in KabupatenJember showed
runs very slowly compared to the development of that the value of ATP is greater than that of WTP. Lack
health insurance in several neighboring countries in of ownership of BadanPenyelenggaraJaminanSosial
ASEAN. Careful research on factors that influence the (BPJS) Health cards among handicraft workers in
development of health insurance in Indonesia is not Jember showed low efficacy on the NHI program even
sufficiently available. Theoretically, several important though the income of handicraft workers is relatively
factors can be stated as the cause of the slow growth of high3. Whereas in the research in the City of
health insurance in Indonesia, including low population Bengkulu, the people who do not have a BPJS Health
demand and income, lack of government will, insurance card are those who are not able to, but the expenditure
culture that has not been good and bad quality of health on cigarettes (essential) is greater than for paying NHI
services, and lack of legal certainty in Indonesia1. contributions each month4. The amount of ATP and
WTP of a person or community in paying contributions
The ability to pay and willingness to pay are two is certainly inseparable from the factors that influence it.
factors that play a role in the utilization of medical Research in the Hulu Sungai Selatan District showed
services which in turn will also affect equity. The ability that greater income and the existence of savings for
to pay can be measured by the approach of calculating health care costs are factors that influence ATP and
family income, family assets, or household expenses. community WTP . In addition, research in Konawe
5

Selatan District revealed that there is a relationship

The willingness to pay can be measured by asking the
between income and utilization of health services by
respondent through two methods, namely what is the
coastal communities6.
real expenditure of individuals/families for health during
a certain period of time and by directly asking how The number of BPJS Health participants for
many individuals are willing to issue health services .
2
Lakkang Island is 571 people or 60% of 952 residents
and those who do not have a BPJS Health card are 381
1036 Indian Journal of Public Health
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Research No. 7 July 2019, Vol.10, No. 7
Development, 1036

people or 40% with 121 family heads. It can be seen that expenditure.
Lakkang Island has not achieved the National Health
Insurance for its population7. Based on the background,
the authors are interested in examining the ability to
pay the National Health Insurance contributions by the
community on Lakkang Island, Makassar City.

Methodology

This type of research is a quantitative study with a

descriptive survey approach that is used to produce an
overview of the ability to pay national health insurance
contributions to the community on the Lakkang Island.
The duration of this research was from January 19 to
February 18, 2017.

The population in this study was the people of

Lakkang Island who had not been covered by NHI. The
number of residents who have not participated in the NHI
program is 381 people, consisting of 121 family heads.
Samples are measures taken from the overall population.
The sample in this study was the head of the family in
Lakkang Island who have not been covered by NHI. Of
the 121 family heads who were sampled, 95 families
were not covered by NHI during the study due to the
presence of people who had enrolled the BPJS Health
during the study and those who had obtained an
Indonesia Health Card. Thus, the number of samples in
this study was 95 people. The sampling procedure used a
saturated sampling method, which is the method of
sampling that often being regarded as a total sample,
where all members of the population are included as
samples8.

The primary data of this study were obtained from

95 respondents through direct interviews using a
prepared questionnaire on matters relating to the
research, namely data on respondent characteristics,
ability to pay data and willingness to pay data.
Secondary data of this study was obtained from the
LakkangPustu report, Lakkang Urban Village report and
other sources related to this research.

Univariate analysis is used to analyze the data in

this research. This analysis produced a frequency
distribution and a percentage of each variable and to
describe the description of each variable in the
distribution table.

ATP 1 = Total income – total expenditure/total

dependents

ATP 2 = 5% of total non-food and non-

essential
1037 Indian Journal of Public Health
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Research No. 7 July 2019, Vol.10, No. 7
Development, 1037
Result and Discussion

Based on the Makassar City minimum wage in

2016, the number of respondents with low-income levels
is 69 people. The number of respondents with sufficient
income was 26 people. This is caused by several factors
such as the area of r ice fields or ponds and the presence
of family members who had helped the head of the
household to fulfil daily life. The increase in commodity
prices (goods and services) and the guidance of daily
living needs make families have to keep thinking of
other ways to get additional income. The low-income
respondents did not participate in the NHI program
because the people of Lakkang Island who mostly
worked as fishermen, entrepreneurs, and informal
workers does not have fixed monthly income and only
earned enough to meet their daily food needs. The
results of this study are in line with the research
conducted by Mudayana9 which stated that family
income affects the ability of patients to pay for health
services. If the patient’s income is still lacking, they
assume that they cannot afford health services. This
research is also in line with the research conducted by
Sihaloho10 whereby high income affected respondents to
become NHI participants and determine their willingness
to pay contributions.

Based on Table 1, it is known that the majority of

respondents with food expenditure of IDR500, 000-
IDR999, 999 are 76 people (80%) since the interview
results revealed that the average monthly food
expenditure of respondents in Lakkang Sub-district is
IDR 775,105. Consumption expenditures are generally
spent on basic needs to meet physical needs. Food
consumption is the most important factor because food
is the main type of goods to maintain survival. Some
respondents also planted crops by planting rice so that
people’s food needs were met without buying rice.

It is also known that the majority of respondents

with non-food expenditure amounted to <IDR500, 000,
as many as 59 people (62.1%). This is because based
on the results of calculations from interviews with all
respondents, the average monthly non-food expenditure
of respondents in Lakkang Sub-District is IDR 4,70,876.
The type of non-food expenditure is the lowest type of
expenditure compared to other expenses. This is because
the lifestyle of the people on Lakkang Island is very
simple. Based on the results of the study, the biggest
non- food expenditure was expenditure on electricity,
gas, and water payments. While the lowest non-food
expenditure
is on durable goods such as kitchen utensils, cutlery and for party, ceremonies, cigarettes, alcohol, snacks and
cellular phones. The results of this study are not in line entertainment expenses that are calculated in units
with the research conducted by Karimah3 which said of rupiah. Most of respondents with non-essential
that the largest household expenditure on handicrafts expenditures amounted to <IDR500,000 - and
was non-food expenditure, because many craft workers’ IDR500,000-IDR999,999, respectively as many as 46
families bought durable goods such as cooking utensils, people (48.4%). This is because based on calculations
both cash and credit. from the results of interviews with all respondents,
the average monthly non-essential expenditure of
Non-essential expenditures are household
respondents in Lakkang is IDR530,715.
expenditures for one month which include expenses

Table 1: Distribution of respondents based on expenditure per month by Lakkang Island community in 2017

Respondent
Expenditure Category Amount
Total (n) Percentage (%)
<500.000 5 5.3
500.000-999999 76 80
1.000.000-1499.999 6 6.3
Food expenditure (IDR)
≥1.500.000 8 8.4
Total 95 100
Mean IDR 775.105
<500.000 59 62.1
500.000-1.000.000 35 36.8
Non-food expenditure ≥1.500.000 1 1.1
Total 95 100
Mean IDR 470.876
<500.000 46 48.4
500.000-999999 46 48.4
Non-essential 1.000.000-1499.999 2 2.1
expenditure ≥1.500.000 1 1.1
Total 95 100
Mean IDR 530.715

The biggest amount of expenditure is spending month which was as many as 58 people (61.1%). While
on cigarettes and snacks. This is because the heads of 37 people (38.9%) were unable to pay the contributions
households in this case are husbands, most of whom are or the ability to pay was not included in the category of
smokers who can spend a pack of cigarettes in a day or care rooms for NHI service classes. Based on Table 2,
two. Based on the results of interviews with respondents it is known that of the 58 respondents who were able to
it is known that the majority of families have school-age pay NHI contributions, as many as 30 people (31.6%)
children. Thus, the expenditure for snacks in one month belonged to the class 1 category. This was because
is quite large even those who have not yet school, have the people in these categories were people who had
also been snacking every day. sufficient income. Furthermore, the results of research
show that respondents with low income but are able
The amount of ATP 1, indicated that most of
to pay the contributions each month. This is due to the
respondents were able to pay NHI contributions
simple living behaviour of the people of Lakkang Island.
each
Table 2: Distribution of respondents based on ATP services. This is because the non-food expenditure of
1 family in the community of Lakkang Island, the Lakkang Village community is not too high. As for
Makassar City in 2017 non-food expenditure for clothes, people buy these items
when necessary, or even during festive seasons, as well
Ability to pay
Contribution as for spending on beauty and durable goods.
Category Total Percentage
(IDR)
(n) (%) The results showed that the average ATP 1
No class <25.500 37 38.9 calculation, respondents were able to pay NHI
Class 3 25.500 19 20.0 contributions every month. These results are in line with
Class 2 51.000 9 9.5 the theory of Adisasmito11 which stated that if a person
Class 1 80.000 30 31.6 is able to spend on non-essential goods, then surely that
Total 95 100 person is also able to pay for essential health services.
If the smoking and snacking behaviour is reduced or
Based on Table 1, the average food expenditure of stopped, the ability to pay for contributions or health
respondents is IDR470,876. If calculated using the 5% services will increase. Yandrizal4’s research indicated
formula multiplied by the non-food expenditure of each that the majority of people who do not have a BPJS
respondent, the average ability to pay the community Health card are those who are not able to, but
was IDR23,554. This means that the respondents with expenditures for shopping for cigarettes are greater than
more non-food expenditures were included in the for paying NHI contributions each month. This research
incapable category, namely 59 people (62.1%). While is also in line with the research conducted by
36 people (37.9%) belong to the category of Noormalasari12 who conducted the research in Jember,
capable. Table 3 shows that of the 36 respondents who saying that on average respondents had consumptive
were able, as many as 35 people (36.8%) belonged to behaviour towards non-
the class 3 category essential expenditures such as cigarettes.

Table 3: Distribution of respondents based on ATP 1 in the community of Lakkang Island, Makassar City in
2017
Non-food Non-essential
Category Contribution (IDR)
n % n %
No class <25.500 59 62.1 46 48.4
Class 3 25.500 35 36.8 46 48.4
Class 2 51.000 1 1.1 2 2.1
Class 1 80.000 0 0 1 1.1
Total 95 100 95 100
The ability to pay using the ATP formula 2 for non- items is IDR1,667,000, average non-essential expenditure
essential expenses, based on Table 4, is more in the of respondents is IDR530,715. The results of this study
capable categories, which are 49 people (51.6%). The are consistent with the research conducted by Putra 7 that
use of the the ability to pay if seen from the average non-essential
5% formula multiplied by non-essential expenditure, the expenditure of respondents of independent paying BPJS
obtained average ability to pay the community is IDR26, participants in Makassar City is IDR 405,484. Such non-
536. From 49 respondents (51.6%) who were able, as essential expenditures should make the head of the family
many as 46 people (48.4%) were included in the category able to finance his family for essential needs such as
of NHI class paying JKN contributions each month, at least in class 3
3 services. This was due to the non-essential expenditure service which is only IDR 25,500.
of Lakkang Island communities such as cigarettes and
snacks. The respondents maximum expenditure for
non-essential

Table 4: Distribution of respondents based on ATP 2 families in the community of Lakkang

Island, Makassar City in 2017
Non-food Non-essential
Ability to pay Total (n) Percentage (%) Total (n) Percentage (%)
Not able 59 62.1 46 48.4
Able 36 37.9 49 51.6
Total 95 100 95 100
Conclusion in low and middle income countries. PLoS
One.
Based on the results of the research and discussion 2016 Jun 30;11(6):e0157470.
that has been described, the following conclusions can
be drawn: 3. Karimah. Karimah. Employees’ ability and
willingness to pay challenges to national health
1. The level of income of respondents is mostly insurance coverage in the North Sulawesi sub-
in the category <IDR1,500,000, which is 38 district of Balung, Jember Regency. Essay.
respondents (40%). If, based on the 2016 Jember: FKM University of Jember. 2015.
Makassar City minimum wage, the majority of
income is in the low category with 69 4. Yandrizal Y, Utami SP. Ability analysis and
respondents (72.6%). The level of respondents’ willingness to pay for the benefits of achieving
expenditure for food averaged Rp.775,105, for UHC JKN in Bengkulu City. Journal of
non-food Rp.470,876 and non-essential Health.
Rp.530,715. The biggest type of expenditure is 2017 Aug 30;10(1):3-10.
spending on food. 5. Handayani E, Gondodiputro S, Saefullah A.
2. The ATP value of the respondents using the Factors that Influence the Willingness of the
ATP Congregation Paying for the Guarantee of Health
1 formula was mostly in the capable category in the District of South Sungai Selatan. Bandung:
of Library of Padjajaran University. 2013.
58 respondents (61.1%) with an average ATP per 6. Karman K, Saptaputra S. Related Factors
person of IDR 90,440 per month. While for the With Utilization of Health Services Share the
ATP 2 formula, the majority are in the category Community of the Coastal Areas of the Village
of non-food for non-food namely 59 respondents in the Province of the District of South Sulawesi
(62.1) with an average ATP of IDR 23,544 and in 2016. Journal of Scientific Community Health
for the most non-essential are in the category Scholarships. 2017 Apr 13;1(3).
of capable of 49 respondents (51.6%) with ATP
average IDR 26,536. 7. Putra. Analysis of ability to pay and catastrophic
payment for independent BPJS Makassar health
payment participants. Thesis. Makassar: Post-
Acknowledgement
Graduate FKM Unhas. 2014.
First and foremost, the authors would like to thank
8. Buraerah. Descriptive analysis of health research
Faculty of Community Health, Hasanuddin University
data. Makassar: Masagena press. 2013.
for their support and facilities in conducting this study.
The authors would also like to thank all the respondents 9. Mudayana AA. Analysis of Ability and
from the community on the Lakkang Island who were Willingness to Pay for Nursing Patients in PKU
willing to participate in this study. Muhammadiyah Hospital, Bantul. Kes Mas:
Ahmad Daulan University Public Health Faculty
Ethical Clearance: Taken from the committee Journal. 2015;9(1).
Source of Funding: Nil 10. Sihaloho EN. Determinants of Willingness to
Pay Contribution to National Health Insurance
Conflict of Interest: Nil Entrepreneurs Independent in Semarang City
Health Service Area (Doctoral dissertation,
REFERENCES Semarang State University).
1. Agustina R, Dartanto T, Sitompul R, Susiloretni 11. Adisasmito W. Second Edition Health System. PT
KA, Achadi EL, Taher A, Wirawan F, Sungkar S, Raja Grafindo Persada, Jakarta. 2014.
Sudarmono P, Shankar AH, Thabrany H.
12. Noormalasari W, Nuryadi N, Sandra C. Ability
Universal health coverage in Indonesia: concept,
To Pay The Premium of National Health
progress, and challenges. The Lancet. 2018 Dec 19.
Insurance for Fishermen in Jember. Health
2. Nosratnejad S, Rashidian A, Dror DM. Systematic Library. 2015 Jan
review of willingness to pay for health insurance 17;3(1):147-54.
DOI Number: 10.5958/0976-5506.2019.01717.0

Factors Associated with Musculoskeletal Disorders (MSDs)

Complaint on the Workers of Cargo Unit at PT. Angkasa Pura
Logistics, Makassar in 2017

Firmita Dwiseli1, Muhammad Rum Rahim1, Awaluddin1

1
Department of Work Safety & Health, Faculty of Community Health, University of
Hasanuddin, Makassar, Indonesia

ABSTRACT
Musculoskeletal complaints are complains on the part of skeletal musclefelt by someone starting from mild
to very severe. When the muscle receives heavy load repeatedly and for a long time, it will lead to complain
on damage of joints, ligaments, and tendons. The observational analytic with cross sectional study done,
aimed to determined factor associated with MSDs complaints on cargo unit workers at PT. Angkasa Pura
Logistics Makassar in 2017. The number of samples as many as 31 people was taken by purposive
sampling technique. Data are taken from respondents using questionnaires, Nordic Body Map, Rapid Entire
Body Assessment (REBA), microtoise and scales. The results showed that there was a relationship between
length of work p= 0.017, work attitude p= 0.036, and Body Mass Index (BMI) p=0.041 with MSDs
complaints oncargo unit workers at PT. Angkasa Pura Logistik Makassar in 2017.

Keywords: MSDs, Musculoskeletal, BMI and PT. Angkasa Pura

Logistics.
Introduction MSDs are one of the increasing occupational
diseases in the world. The results of research conducted
Musculoskeletal hazards are a disorder or decrease
by Cindyastira et al.4 on production workers in CV.
in the condition of the musculoskeletal system
SumberGalian Makassar found the prevalence of MSDs
commonly referred to as Musculoskeletal Disorders
complaints felt by 26 workers (60%). The statistical
(MSDs). MSDs are a major cause of industrial injury
results show that the age variable, work period variables,
in both developed and developing countries1. MSDs can
exercise habits, and work attitude variables have a
be one of the factors causing a decline in production, significant relationship with complaints of MSDs,
loss of working hours, high costs treatment and material, whereas the vibration intensity variable and the longer
increased absenteeism, low quality of work, injury working duration variable have no significant relationship
and muscle tension, increased likelihood of workplace with MSDs complaints. Research conducted on tofu
accidents and errors, increased labor turnover costs and factory workers in East Bara-Baraya Village, Makassar
reduced reserves associated with emergencies2. City showed that MSDs complaints were felt by 42
Complaints of the musculoskeletal system are workers (66.7%). The results of statistical tests show that
complaints to parts of the skeletal muscles that are felt the variables of age, smoking habits, and years of service
by a person ranging from mild complaints to very sick. and work posture are related to complaints of MSDs5.
If the muscle receives a static load repeatedly and for a PT. Angkasa Pura Logistik is a subsidiary of
long time, it can cause complaints in the form of damage PT.Angkasa Pura I (Persero) which is engaged in
to joints, ligaments and tendons. Work attitude that logistics in Indonesia. Based on the preliminary survey
causes the position of parts the body moves away from its that has been carried out, the work process in the cargo
natural position, for example hand movements are raised, unit includes the receipt of goods, weighing, making/
the back is too bent and the head is raised. The farther the checking transport documents, storing goods in the
body part of the body’s gravity, the higher the risk of warehouse until the process of goods is loaded into
occurrence complaints of the musculoskeletal system3. cargo compartment, withdrawing goods from the
warehouse
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to the aircraft and vice versa, loading goods loading) is 111 people. From this population, the sample study
to the aircraft and unloading of aircraft, storage and was workers in the cargo unit of PT. Angkasa Pura
shipping. From the types of work, some processes are Logistics, who works in the afternoon shift (35 people).
still done manually, for example the process of lifting Sampling is done using purposive sampling techniques,
and moving items. This work process is usually called namely sampling based on certain characteristics
manual handling. Manual handling operations are all considered to have a close relationship with the
activities of transporting or sustaining loads (including characteristics of the population that were previously
lifting, placing, pushing, pulling, carrying, or moving) known. The inclusion criteria used in this study are as
by hand or body strength6. follows:

Manually lifting activities can cause complaints a. Minimum 1-year work period. This is done
about skeletal muscles often referred to as because of MSDs complaints is a complain that
musculoskeletal complaints. Moreover, if the activity of can arise due to a monotonous work process and
lifting weights manually is done with repetitive positions continuous load over a relatively long period of
or working attitudes repeatedly every day the possibility time.
of a musculoskeletal complaint is greater. The results of
b. Work in the afternoon shift during the study
Jaya7 research show that there is a relationship between
period.
the weight of goods and MSDs complaints on CV
Cahaya Malang Raya Makassa employees. Masliah et al. Data on complaints of Musculoskeletal Disorders
8
research results on manual handling workers in (MSDs) were obtained by using the Nordic Body
Makassar Port showed that there was a relationship Map questionnaire. Primary data regarding name and
between work posture and MSDs complaints age were obtained through direct interviews with
experienced by workers. In addition to being able to respondents using questionnaire. Data on load weight
carry out their duties well, workers also need good is obtained from the weight of the object shown on
physical condition. This is necessary because every day packed weights. Data regarding work posture is obtained
workers are required to lift heavy items, it needs a large through the calculation of MSDs risk on certain body
work capacity so as not to cause harm. Based on parts (neck, spine, upper arms & bottom, wrist) using
preliminary data obtained from the administrative the Rapid Entire Body Assessment scoring sheet. Data
division of PT. Angkasa Pura Logistics, the number of on Body Mass Index is obtained through weight and
workers in the cargo unit is 111 people with working height measurement of the worker using weight scales
experience of generally less than 3 years. Workers work and microtoise, then calculated using the IMT formula.
Secondary data was obtained from the company in
every day from Monday to Sunday. Based on the
the form of data regarding company profiles and the
description of the background above, the authors are
number of workers in the cargo unit of PT. Angkasa
interested in conducting research on factors related to
Pura Logistics Makassar. All the gathered data were
complaints of Musculoskeletal Disorders (MSDs) in
analyzed using SPSS program which consist of
cargo unit workers at PT. Angkasa Pura Logistik
univariate analysis and bivariate analysis.
Makassar.

Result and Discussion

Methodology
Univariate Analysis: Respondents’ distribution based
The type of research used is observational analytic
on Musculoskeletal Disorders (MSDs) complaints is
research with cross sectional study approach, with the shown in Table 1 which was obtained from interviews
intentions of perceiving the relationship between the using the Nordic Body Map questionnaire. It shows
independent variables and the dependent variable which that out of 35 respondents, 21 people (60%) experienced
is the relationship between weight burden, work attitude, MSDs while the number of respondents who did not
and BMI with MSDs complaints among workers in experience MSDs was 14 people (40%).This study
cargo unit at PT. Angkasa Pura Logistics Makassar.The categorizes the weight variable into two categories
research was conducted at PT. Angkasa Pura Logistics namely heavy and light. Based on Table 1, it can be
Makassar from January 2017 to April 2017. seen that, 21 people (60%) who lifts heavy loads while
working whereas remaining people involves in light
The population in this study was all porter workers in loads. As for work attitude category,itt can be
the unit cargo PT. Angkasa Pura Logistik Makassar, concluded that a total of 20 people (57.1%) exhibit
which
risky work attitude in contrast
to the remaining 15 people (42.9%).In this study, BMI ideal consists of those who are underweight, overweight,
was categorized into two; which are ideal category if and obese. Data shows that out of 35 respondents, there
the BMI is between 18.5 – 25.0 kg/m 2 and the non-ideal were 17 people (48.6%) who had ideal BMI and 18
category if BMI <18.5 kg/m2 or BMI> 25 kg/m2. Non- people (51.4%) with non-ideal BMI.

Table 1: Distribution of respondents based on MSDs complaints, weight load, work attitude and body mass
index at PT. Angkasa Pura Logistics Makassar workers in 2017

Category Frequency (n) Percentage (%)

Have complains 21 60
Complaints of MSDs
No complains 14 40
Heavy 21 60
Weight load
Light 14 40
Risky 20 57.1
Work attitude
Non-risky 15 42.9
Ideal 17 48.6
Body mass index
Non-ideal 18 51.4
Bivariate Analysis: The bivariate analysis results of by Masliah et al.8 regarding MSDs complaints of workers
the relationships between weight burden and MSDs in manual handling at Makassar port, which showed to
complaints at PT Angkasa Pura Logistics is presented in have a significant relationship between complaints of
Table 2. It shows that of all respondents who involved musculoskeletal disorders and the weight of the burden.
in lifting heavy loads, there were 16 people (76.2%) If the weight of the load exceeds the work capacity of
who experienced MSDs while 5 people (35.7%) did not workers, it can cause interference to workers. The heavier
complain of MSDs. While respondents who were the burden received by a worker, the greater the
involved in lifting light loads, 5 respondents do have likelihood of disruption to the physical of the worker,
MSDs while 9 people (64.3%) did not experience any especially at parts of the muscles and bones. This is
MSDs. Based on the results of data analysis using Chi- because the heavier the objects, the greater the energy
square test, the value of p = 0.017 which indicated that that presses on the muscles to stabilize the spine and
there is a relationship between weights and complaints of produces greater pressure on the spine. Due to
MSDs in cargo unit workers at PT Angkasa Pura transporting loads that are too heavy or too weak,
Logistics Makassar. The results of this study are in line physical abilities can cause a worker to suffer a disorder
with the research conducted or disease9.
Table 2: Relationship between load weight and MSDs complains among workers at PT. Angkasa Pura
Logistics Makassar in 2017
MSDs complains Total
Weight
Have complain No complain p
load n %
n % n %
Heavy 16 76.2 5 23.8 21 60.0
Light 5 35.7 9 64.3 14 40.0 0.017
Total 21 60 14 40 35 100
An overview of the bivariate analysis results of contrast, respondents who has complains of MSDs
the relationships between work attitudes and MSDs comprises of 5 people (25%) with risky work attitudes
complains at PT Angkasa Pura Logistics is shown in and 9 people (60%) with non-risky work attitudes.
Table 3. Respondents with risky work attitudes who Based on the results of data analysis using Chi-square
experienced MSDs were as many as 15 people (75%) test, the value of p = 0.036 which indicated that there
while workers who demonstrate non-risk work attitude is a relationship between work attitudes and complaints
and had MSDs disorders, namely 6 people (40%). of Musculoskeletal Disorders (MSDs) in cargo unit
In
workers at PT Angkasa Pura Logistics Makassar. This of the body part from the center of gravity, the higher
research is in line with the research conducted by the complaints of skeletal muscles also occur. Work
Riyanto10 regarding the effect of manual lifting work on attitudes are not generally due to workers
complaints of the musculoskeletal system in workers at ‘incompatibility with workers’ abilities11. The attitude
PT. SidoMuncul Semarang as the p value is 0.001. An and work position that are not ergonomic have the
unnatural work attitude causes the body part to move potential to cause some health problems, including
away from its natural position. The farther the muscle fatigue, pain, and vascularity disorders12.
position

Table 3: Relationship between work attitude and MSDs complaints among workers at PT. Angkasa Pura
Logistics Makassar in 2017
MSDs complains Total
Work attitude Have complain No complain p
n %
n % n %
Risky 15 75 5 25 20 57.1
Non-risky 6 40 9 60 15 42.9 0.036
Total 21 60 14 40 35 100
Table 4 presented the bivariate analysis results of of individual characteristics and manual material
the relationships between BMI and MSDs complains at handling (MMH) to workers in the TanjungJember
PT Angkasa Pura Logistics. It can be observed that out Market. He obtained p = 0.041 which concluded that
of 35 respondents, the number of respondents with ideal there is a relationship between BMI and MSDs
BMI who had MSDs complains was as many as 14 complaints. BMI associated with musculoskeletal
people (77.8%) while 7 people (41.2%) in non-ideal BMI complaints are the results in the body not being able to
category raised MSDs complains. Respondents who has sustain body weight that makes the body feel pain.
ideal BMI and did not have any MSDs were 4 people Overweight and obesity leads to serious health
(22.2%) while remaining 10 people (58.8%) are in the consequences. Risks are increasing along with increasing
non-ideal BMI category and did not have any MSDs. BMI. Body mass index is a major risk factor for chronic
Based on the results of statistical analysis using the diseases osteoarthritis14. Meanwhile, underweight
Fisher Exact, the value of p = 0.027 which tells there do workers also have the potential to experience complaints
exist relationship between Body Mass Index (BMI) with of MSDs due to the inability of their bodies to support
complaints of MSDs. The results of this study are in line heavy loads. The possibility of injury or sprains when
with the research conducted by As’Adi et al.13 workers lifting weights is greater than workers who have a
who measured the relationship proportional body.
Table 4: Relationship between work attitude and MSDs complaints among workers at PT. Angkasa Pura
Logistics Makassar in 2017
MSDs complains Total
BMI Have complain No complain p
n %
n % n %
Ideal 14 77.8 4 22.2 18 51.4
Non-ideal 7 41.2 10 58.8 17 48.6 0.041
Total 21 40 14 60 35 100
Conclusion a. The heavier the burden received by workers,
the
Based on the results of research on factors related to more likely it is to experience MSDs complains.
complaints of Musculoskeletal Disorders (MSDs) in b. Workers need to practice ergonomic work attitude
cargo service workers at PT Angkasa Pura Logistics in order to reduce MSDs occurrences.
Makassar in 2017, some conclusions were obtained as c. Maintaining BMI in ideal category helps the
follows: workers from MSDs risks.
Acknowledgement 6. Ridley J. Occupational health and safety. Jakarta:
Erlangga. 2006.
The authors would like to thank Faculty of
Community Health, Hasanuddin University for their 7. Jaya I. Factors related to complaints of
support and facilities in conducting this study. In musculoskeletal disorders (msds) in manual
addition, the authors would also like to thank all the handling activities by employees of CV.
respondents from Cargo Unit at PT. Angkasa Pura CahayaMajang Raya (CAMAR) Makassar in
Logistics who was willing to participate in this study. 2015. (thesis, Hasanuddin University)
8. Masliah SS, Rahim MR. Factors related to
Ethical Clearance: Taken from the committee
complaints of musculoskeletal disorders (MSDs)
Source of Funding: Nil in manual handling workers at Makassar Port
(thesis, Hasanuddin University)
Conflict of Interest: Nil
9. McGill SM. Low back disorders: evidence-based
prevention and rehabilitation. Human Kinetics;
REFERENCES 2015 Nov 17.
1. Gallagher S, Schall Jr MC. Musculoskeletal 10. Riyanto, A. Influence of Attitude Working
disorders as a fatigue failure process: evidence, on the Manual Focus on Complaints on the
implications and research needs. Mollusculoskeletal System in the Workers of
Ergonomics. the Push in Pt. SidoMuncul Semarang (Doctoral
2017 Feb 1;60(2):255-69. dissertation, Muhammadiyah University
2. Macdonald W, Oakman J. Requirements for Surakarta).
more effective prevention of work-related 11. Fuady AR. Factors Associated with Complaints
musculoskeletal disorders.BMC musculoskeletal on Musculoskeletal Disorders (MSDs) at Shoe
disorders. 2015 Dec;16(1):293. Craftsmen in Small Industrial Village (PIK)
3. Choi HW, Kim YK, Kang DM, Kim JE, Jang BY. Grinding District of North Jakarta in 2013.
Characteristics of occupational musculoskeletal 12. Widana IK, Sumetri NW, Sutapa IK. Effect
disorders of five sectors in service industry of improvement on work attitudes and work
between 2004 and 2013.Annals of Occupational environment on decreasing occupational pain.
and Environmental Medicine. 2017 Dec;29(1):41. International journal of life sciences. 2018 Oct
4. Cindyastira D, Russeng SS, Wahyuni A. 29;2(3):86-97.
Vibration Intensity with Complaints on 13. As’ Adi AM, Sujoso AD, Prasetyowati I. The
Musculoskeletal Disorders (Msds). Public Health Relationship Between Individual Characteristics
Media Indonesia. and Manual Material Handling With
2016 Jun 22;10(4):234-40. Musculosceletal Complaints Due To Work.
Health Library. 2014 May 5;2(2):271-6.
5. Oei VTW, Wahyu A, Rahim MR. Factors
Associated with Complaints on Musculoskeletal 14. Zulfiqor MT. Factors related to complaints
Disorders (MSDs) in Workers of Tofu Factory in ofculosletal disorders in welder in the fabrication
Bara Barayya District East Kalimantan Makassar section of PT. Caterpillar Indonesia.
City District in 2016. (thesis, Hasanuddin
University)
DOI Number: 10.5958/0976-5506.2019.01718.2

Relationship between Heat Pressure and Age with Work

Fatigue among Workers at Department Factory I of Pt.
Maruki International, Makassar in 2017

Ulfa Rahman1, Masyitha Muis1, FurqaanNaiem1

1
Department of Work Safety &Health, Faculty of Community Health, University of
Hasanuddin, Makassar, Indonesia

ABSTRACT
PT. Maruki International Indonesia is the only company in Indonesia that exports Butsudan. Production
activities are divided into 6 factories. The initial process that has high activity and has high heat pressure
sourced from the engine takes place in Factory 1. Hence, this can cause workers to experience fatigue
easily. This study aimed to determine the relationship of heat pressure and age with work fatigue
experienced by Factory 1 workers at PT. Maruki International Indonesia Makassar City. The type of
research is observational analytic with a cross sectional study approach. Data collection from 48 workers
took place from April 10 to April 15, 2017. The work fatigue measurement technique used the Reaction
timer tool, heat pressure using Heat Stress Monitor equipment, and age through direct interview. Data
analyses were done using Chi-square test. The results showed that there was a relationship between heat
pressure p = 0.014 (p <0.05) and age p =
0.026 (p <0.05 with work fatigue at factory I workers of PT. Maruki International Indonesia.
Keywords: PT. Maruki International, Fatigue, temperature and factory I
workers.
Introduction heat pressure can lead to various health problems,
work accidents to death. Human ability to adapt to
Fatigue is a mechanism for protecting the body so
environmental temperature is generally seen from
that the body can avoid further damage resulting in
changes in body temperature. Humans are considered
recovery after rest1.The term fatigue leads to the
able to adapt to changes in environmental temperature
condition of weakening of energy to carry out an
if temperature changes do not occur or changes in
activity. Symptoms of subjective and objective fatigue
body temperature whereby still in a safe range4. The
include feelings of lethargy, sleepiness, dizziness, lack
local temperature and existence of life are very closely
of concentration, lack of alertness, poor and slow
related, as are the effects of work weather on labour
perception, reduced arousal for work and decreased
power. Work efficiency is greatly influenced by working
spiritual and physical performance. Fatigue can affect
weather in areas where work is not cold and not hot. The
work productivity, so that if the level of productivity of
recommended temperature in the workplace is around
a workforce is disrupted caused by physical or
24-
psychological factors, then the result will be felt by the
26 ° C (cold temperature) and humidity of 65% - 95%3.
company in the form of decreased in productivity2.
Workers in hot environments, such as around
Workers will be able to carry out activities well and furnaces, smelters, boilers, ovens, heat sinks or working
work optimally under conducive working environment. under the hot sun can experience heat stress5. These
The comfort of a workplace is influenced by several thermal conditions can affect the performance of
factors, one of which is the work climate. Work climate workers both working outside and inside buildings. The
is a combination of air temperature, air humidity, air effectiveness of the performance of workers in the two
movement speed and radiation temperature in a work work locations is strongly influenced by the comfort of
environment3. If these four components interact with the work environment where they are located, especially
heat, it will potentially cause heat stress. Excessive for workers who are in building6. The United States
Emergency Department reports that the number of work
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accident patients due to heat stress in the workplace has 1 of PT. Maruki International Indonesia Makassar City.
increased significantly from 3,192 cases in 1997 to 7,452 Data collection began on 10 April until 15 April 2017
in 20067. Based on research conducted by Indriawati 8 against 48 workers in the factory as samples taken with
about the effect of heat pressure on the fatigue level
of work at the concert slab steel plant I PT. Krakatau
Steel Cilegon, Banteng shows that there is a relationship
between heat pressure and work pressure in the concrete
section, namely the higher the heat pressure in the work
environment, the higher the level of fatigue of workers.
Conversely the lower the heat pressure in the workplace
the lower the work fatigue of the workers.

Individual factors such as age, nutritional status and

haemoglobin levels also greatly influence the occurrence
of work fatigue. Research by Damopoli et al.9 concluded
that there is a relationship between age and work fatigue
at the Manado-Amurang bus driver at Malayan terminal.
The age of bus driver is directly proportional to the level
of fatigue. The results of research conducted by Febriani
et al.10 on the relationship of heat pressure to fatigue
in tofu maker workers of Tofu Factory in East Bara-
Barayya Sub-District, in 2016 showed that as many
as
43 respondents obtained more work fatigue in the status
category. 29 respondents (82.9%) experienced abnormal
nutritional compared to the normal nutritional status
category as many as 14 respondents (50.0%).

PT Maruki International Indonesia is the only

company in Indonesia that exports Butsudan (furniture
that serves as a place to respect and communicate with
deceased ancestors). Types of activities carried out at
PT. Maruki International Indonesia, namely wood
drying, woodcutting, refinement, gluing, colouring,
assembly and packaging. Examples of complaints by
workers during the research work include quickly
feeling tired, fast thirst, dizziness, and excessive
sweating. This is the background of researchers wanting
to conduct research with the title “Relationship between
Heat Pressure and Age with Fatigue among Workers in
Factory I Section at PT. Maruki International Indonesia
Makassar City 2017.

Methodology

The type of research used is observational analytic

research with a cross sectional study approach as the
independent and dependent variables will be observed at
the same time. This research was conducted at the
factory
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exhaustive sampling techniques. The data were collected
using direct interviews (questionnaires) as to find out the
age and heat pressure measurements using a Heat Stress
Monitor measuring device. Furthermore, work fatigue
measurements were carried out using a reaction timer
on a sample of 48 workers. The data obtained is then
analyzed using the SPSS computer program and the data
is presented in the form of a frequency table and cross
tabulation (crosstab) in accordance with the research
objectives and accompanied by a narrative as a table
explanation.

Result and Discussion

Univariate Analysis: Distribution of respondents

according to work fatigue group can be seen in
Table
1. Based on Table 1, it is shown that the highest number
of respondents is in the reaction time group 198-239
milliseconds as many as 18 respondents or 37.5% while
the least number of respondents is in the reaction time
group 502-543 milliseconds as many as 2 respondents
or 4.3%.

Table 1: Distribution of respondents by fatigue

group

Respondents
Fatigue group
n Percentage (%)
198 – 239 18 37.5
240 – 381 5 10.4
282– 323 3 6.2
324– 365 4 8.4
366– 407 3 6.2
408 – 459 3 6.2
460 – 501 4 8.4
502 – 543 2 4.3
544 – 585 3 6.2
586 – 627 3 6.2
Total 48 100

After grouping the fatigue level based on the

reaction time of workers, work fatigue in this study is
then divided into 2 categories, namely fatigue if the
reaction time is ≥ 240 milliseconds and not fatigued if
the reaction time is <240 milliseconds. Data in Table 2
presented that from 48 respondents, it was known that
respondents who experienced fatigue were 30 people or
62.5% whereas those who did not experience fatigue is
as many as 18 people or 37.5%.
Table 2: Distribution of respondents by fatigue 49 as many as 11 respondents or 22.9% while the least
category number of respondents is in the age group 55-59 years as
many as 4 respondents or 8.4%.
Respondents
Fatigue category
n Percentage (%) Table 4: Distribution of respondents by age group
Experienced fatigue 30 62.5
Respondents
No fatigue experience 18 37.5 Age group
n Percentage (%)
Total 48 100
20-24 6 12.5
Data presentation based on distribution of
respondent according to heat pressure can be seen in 25-29 6 12.5
Table 3. Heat pressure is categorized into 2 categories, 30-34 5 10.4
namely meeting the requirements for Wet Bulb Globe 35-39 5 10.4
Temperature Index (WBGT) of not exceeding threshold 40-44 6 12.5
value 28̊C and not meeting the requirements if the 45-49 11 22.9
WBGT does not pass the threshold value (> 28̊C). The 50-54 5 10.4
data in Table 3 showed that from 48 respondents, it was 55-59 4 8.4
obtained as many as 32 people or 66.7% who worked Total 48 100
under heat pressure did not meet the requirements and Bivariate Analysis: The results of cross tabulation
16 people or equal to 33.3% worked on heat pressure between heat stress and fatigue can be seen in
that met the requirements. Table
5 which revealed that from 48 respondents, most of
Table 3: Distribution of respondents by heat workers that experienced work fatigue working under
pressure category heat pressure (did not meet the requirements), as
many as 24 respondents or 75.0% compared to those
Respondents working under heat pressure (met the requirements)
Heat pressure category
n Percentage (%) of
Did not meet the requirement 32 66.7 6 respondents or 37.5%. The number of respondents
Met the requirement 16 33.3 who did not experience fatigue but worked under heat
Total 48 100 pressure (within the requirements), were as many as 10
respondents or 62.5% whereas those who worked under
Distribution of respondents based on age group is heat pressure (did not meet the requirements), namely as
tabulated in Table 4.The age of respondents working at many as 8 respondents or 25.0%. Based on data analysis
Factory I ranged from 20-59 years. Based on table 4, the using the Chi square test, the value of p = 0.014. The
highest number of respondents is in the age group 45- interpretation is that there is a connection between heat
stress and work fatigue.
Table 5: Relationship between heat stress and work fatigue
Work fatigue Total
Heat stress Experienced fatigue No fatigue experience p-value
n %
n % n %
Did not meet requirement (>28̊C) 24 75.0 8 25.0 2 66.7
Met requirement (≤28̊C) 6 37.5 10 62.5 6 33.3 0.014
Total 30 62.5 18 37.5 8 100
The following are the results of cross tabulation respondents or 41.2%, while the percentage who did not
between age and work fatigue which can be seen in Table experience work fatigue in the young age category were
6. Table 6 showed that of the 48 respondents those who as many as 10 respondents or 58.8% and in the old
experienced work fatigue were in the old age (35 years category
and above) category as many as 23 respondents or 74.2% 8 respondents or 25.8%. Based on data analysis using the
compared to the young age category that is as many as 7 Chi square test, the obtained p value = 0.026. Thus, there
is a relationship between age and work fatigue.
Table 6: Relationship between age and work fatigue

Work fatigue Total

Age Experienced fatigue No fatigue experience p-value
n %
n % n %
Old (≥35 years) 23 74.2 8 25.8 31 64.6
Young (<35 years) 7 41.2 10 58.8 17 35.4 0.026
Total 30 62.5 18 37.5 48 100
Discussion Although most respondents who experience work
fatigue are included in the old age category, but there
The results of the heat pressure received by workers
are 8 respondents who are in the old age category
vary depending on which production process the worker
whom did not experience fatigue. This can be caused by
works. In addition to work processes that are exposed to
workers utilizing their rest periods well. In addition, in
heat, the condition of buildings and roofs made of zinc
the young age category, 7 respondents experienced work
and not equipped with air vents (exhaust fans) increase
fatigue. Based on the results of interviews, these workers
the factor of heat stress in the workplace is higher. If
had poor sleep patterns. This is due to other activities
workers are exposed to heat, the organs will work
after working like additional work, experiencing sleep
harder to remove excess heat from the body, causing
disorders (insomnia) and the habit of spending time late
the hypothalamus to stimulate the sweat glands so that
the body will sweat. In sweat contains various sodium at night after returning to work.
chloride salts, the release of sodium chloride salt with
sweat will reduce levels in the body, thus inhibiting the Conclusion
transportation of glucose as an energy source. This will
Based on the results of research and analysis of the
cause a decrease in muscle contraction so that the body
variables studied about the relationship of heat pressure
experiences fatigue11. This was reinforced by complaints
and the characteristics of individuals with work fatigue
from workers when researchers conducted interviews,
on workers at the factory 1 of PT. Maruki International
where most workers experienced dehydration,
headaches, excessive sweating and complained of the Indonesia Makassar City In 2017 it can be concluded
existence of a hot environment. Based on the results of that:
data analysis and observations, it can be concluded that 1. The higher the temperature of the environment in
the higher the heat pressure, the respondents will be at the workplace, the faster the workers experience
risk of experiencing work fatigue. This research is in work fatigue.
line with the research conducted by Indriawati 8 which
2. The older the age of a worker, the faster they
stated that there is a significant relationship between
heat pressure and work fatigue among workers at the experience work fatigue.
Concrete Slab Steel Plan 1 PT. Krakatau Steel Cilegon,
Bantensince obtained p value = 0.002. Acknowledgement

In this study, there is a relationship between age and The authors would like to thank Faculty of
work fatigue whereby the older a person is, the lower Community Health, Hasanuddin University for their
the body’s strength which result in faster work fatigue. support and facilities in conducting this study. The
A person’s age will affect the condition and capacity authors would also like to thank all the respondents from
of the body in carrying out its activities. Workers over Department Factory I of Pt. Maruki International who
the age of 35 have fatigue when doing work under was willing to participate in this study.
hot temperatures compared to younger workers12. The
results of this study are not in line with the research Ethical Clearance: Taken from the committee
conducted by Winwood et al.13 where young workers are Source of Funding: Nil
easily tired than old age employees.
Conflict of Interest: Nil
REFERENCES 8. Indriawati A. Effect of Heat Pressure on Work
1. Krueger GP. 14 Α Fatigue.Human Error in Fatigue at Concast Slab Steel Plant 1 at PT
Medicine. 2018 Feb 6:187. Krakatau Steel. (doctorate dissertation, Sebelas
Maret University).
2. Gander P, Hartley L, Powell D, Cabon P,
Hitchcock E, Mills A, Popkin S. Fatigue risk 9. Damopoli FC, Paul AT, Raini AT. Factors
management: Organizational factors at the Associated with Work Fatigue at Route-Driver
regulatory and industry/company level. Accident Manado-Amurang at Malalayang Terminal
Analysis & Prevention. 2011 Mar 1;43(2):573-90. Manado. Skirpsi. Field of Health Care Workers.
Faculty of Public Health. 2013.
3. De Been I, Van Der Voordt T, Haynes B.
Productivity. Facilities Management and 10. Febriani E, RahimMR,Wahyuni, A. Relationship
Corporate Real Estate Management as Value between Heat Pressure and Fatigue in Tofu
Drivers: How to Manage and Measure Added Factory Workers in Bara-Baraya Subdistrict, East
Value, Routledge, Abingdon. 2016 Oct 4:140-55. Sumatra District Makassar City Makassar, 2016.
(thesis, Hasanuddin University)
4. Irzal MK. Basics of Health and Safety: Edition 1.
Kencana. 2016 Nov 1. 11. Hall JE. Guyton and Hall Textbook of Medical
Physiology E-Book: with STUDENT CONSULT
5. Listrianti AW, Naiem MF, Muis M. Relationship Online Access. Elsevier Health Sciences; 2010 Jul
between Heat Pressure and Fatigue of Nutritional 19.
Installation Workers at Makassar City Hospital.
Journal of Public Health. 2014: 1-10. 12. Salasa N, Kolibu FK, Punuh MI. Relationship
Between Age, Work Period and Nutritional
6. Mukti IF, Huda LN, Matondang AR. Design Status With Exhaustion of Work on Workers
of Environmental Improvement Work for Use in the Loining Section of PT. Sinar Pure Foods
Reduced Exposure Heat Work Operator at PT. International Bitung. Health Media. 2017;9(3).
Xy. USU Industrial Engineering Journal. 2013
Feb 24;1(1). 13. Winwood PC, Winefield AH, Lushington
K. Work‐related fatigue and recovery: the
7. Fuhrmann CM, Sugg MM, Konrad CE, Waller contribution of age, domestic responsibilities and
A. Impact of extreme heat events on emergency shift work. Journal of Advanced Nursing. 2006
department visits in North Carolina (2007– Nov;56(4):438-49.
2011). Journal of community health. 2016 Feb
1;41(1):146-56.
DOI Number: 10.5958/0976-5506.2019.01719.4

Relationship of Health Service Quality with Inpatients’ Loyalty

at RSUD M akassar City

Sri Wahyuni1, Nurhayani1, H. Indar1

1
Department of Administration & Health Policy, Faculty of Community Health, University of Hasanuddin,
Makassar, Indonesia

ABSTRACT
The purpose of this research is to get an illustration about the relationship of quality of health service with
the loyalty of inpatients in RSUD Makassar City. This research type is quantitative research with cross
sectional design. A total sample of 95 respondents is determined by the accidental sampling technique.
The data collection is done using questionnaire. The result of Chi-square test (p <0.05) on service quality
variables was correlated between responsiveness (p = 0.007), assurance (p = 0.000), and reliability
(p =
0.013) toward loyalty of inpatients in RSUD Makassar City. Meanwhile, service quality variables have
no relation between tangibility (p = 0.901) toward loyalty of inpatient patient in RSUD Kota Makassar.
In conclusion, there is relation between quality of health service variable with patient loyalty including,
dimension of responsiveness, and assurance. However, there is no correlation between the variable of
health service quality and patient loyalty in tangibility dimension. Thus, it is recommended that the hospital
speed up the process of renovation of the rooms, hospitalization and complement each room according to
the needs of patients in RSUD City.

Keywords: Health Service, Quality, Inpatients, Loyalty and RSUD.

Introduction Based on Gunawan et al.4’s research results on the
quality of patient service and loyalty, the results showed
Healthcare providers such as hospitals, health
that the service quality consisted of tangibility, empathy,
centers, medical centers and medical practices are form
reliability, responsiveness and assurance had partial
of provision of health resources which need to have
effect on patient’s loyalty. Research conducted by
quality services that are in line with the expectations
Mahamad et al.5 showed that empathy, reliability,
of the community1. Health personnel (doctors, nurses, responsiveness, assurance, and tangibility had positive
medical and non-medical support staff in the hospital) and significant influence on customer’s satisfaction and
must understand how to serve consumers well, loyalty. The results of the study conducted by Asmita6
especially patients, since they are the primary revealed that patient’s perception about doctor’s
consumers2. There are many things to consider in medical skill was not good at 50.9%, perception of
improving the health status of the community, one of doctor attitude was not good at 49.1%, perception of
which is to provide health services for instance any information delivery was not good equal to 53.6 %,
individual or collective effort in an organization to timekeepingservice perceptions were poor with
nurture and improve the health of individuals, families, 59.1%, perception of doctor’s time consultation was
groups or communities, and the establishment of health not good with 52.7% and less loyal patients 56.4%.
care facilities such as health centers and hospitals 3. Research by Berlianty et al.7, showed that there is a
Quality as a concept is applied and practiced in the same significant relationship between all variables with
manner and style in every circumstance. Health care patients’ loyalty, the related variables are responsiveness
must understand the health status and needs of the public p (0.00), assurance p (0.03), tangibility p (0.03),
health services it serves in determining the most empathy p (0.03), and reliability p (0.01). While the
effective way to provide a quality healthcare. results of research conducted by Hidayah8, proved that
the variables associated with the loyalty of inpatient
1051 Indian Journal of Public Health
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Journal &
of Development,
Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1051

patients were reliability (p = 0.006), empathy (p = In this study, the primary data is obtained through
0.000), and brand personality (p = 0.007). Variables that questionnaires that have been prepared and distributed
were not related to loyalty of inpatients is affordability to the respondents to be filled up whereas the secondary
variable (p = 0.314). data is obtained from document collection such as
annual report and profile of Makassar City Hospital,
Based on reports from RSUD Makassar from 2014 to and other sources related to research. The collected
2016, there has been a decreased in the number of data were analyzed using SPSS program for
patients especially from year 2015 to 2016 with a univariate analysis and bivariate analysis with
reduction of number of patient visits as many as 3358 responsiveness, assurance, and tangibility as
patients.This is likely to be due to the quality of health independent variables while loyalty as the dependent
services in inpatient admission was in poor condition. variable.
Consequently, patients are not loyal to re-utilizing the
service in the hospital. Therefore, this study is interested Result and Discussion
to know the quality of health service quality with patient
Univariate Analysis: The distribution of respondents
inpatient loyalty at RSUD Makassar City for the year
scoring based on responsiveness dimension statements
2017 based on tangibility, responsiveness and assurance
is tabulated in Table 1. Based on the description of the
factors.
statement the dimension of responsiveness in the first
statement, no respondents who rated strongly agree and
Methodology strongly disagree, while 87 respondents rated disagree.
In statement number two, 89.5% did not agree, and
This quantitative research applied an observational
similar to the first statement, 0 respondents strongly
analytic with cross sectional approach which is meant to
disagree and strongly disagree. In statement number
identify the relationship between health service quality
three, there are 4 respondents who rated strongly agree,
with patient loyalty in RSUD Makassar City. The study 36 respondents judged agree, 55 respondents who did
conducted in RSUD Kota Makassar (located at Jl. not agree and 0 respondents who rated strongly disagree.
Pioneer of Independence Km 14 Daya, Makassar For the fourth statement, there are 12 respondents
(Provincial Poros Road), was from 10th to 30th April 2017. (12.6%) who ranked strongly agree, 44 respondents
(46.3%) judged agree, 39 respondents (41.1%) who
The population in this study was all patients in
rated disagree, 0 respondents (0.0%) strongly disagreed.
the
In statement number five, there are 20 respondents
care unit staying in Makassar Municipal Hospital in
(21.1%) who rated strongly agree, 37 respondents
2016 as many as 9228 people.Sampling technique used
(38.9%), rated agree, 38 respondents (40.0%) who
in this research was ‘accidental sampling technique’ that
did not agree, and
is the simplest sampling technique, because the sample 0 respondents (0.0%) who strongly disagreed. For the
coincidently exists at the time of the research and meets last statement, there are 0 respondents (0.0%) who rate
the criteria for research sample. The criteria for the strongly agreed and disagreed, 40 respondents (42.1%)
samples are as follow: agreed, and 55 respondents (57.9%) who did not agree.
a. Willing to be a respondent in this study. This is due to doctors are quick and responsive in
providing services, and nurses inform quickly if there
b. Respondents are patients who have more than two is a delay in providing health services. However, on
visits. the other hand from the results of data collection in the
field, there are some respondents who judge poorly on
c. Respondents are able to understand the questions/
the responsiveness dimension because most respondents
statements contained in questionnaire and answer
rated not all nurses in Makassar City Hospital are quick
the question itself. For respondents who have
and responsive in providing health services to patients.
difficulty completing the questionnaire, they can
Therefore, health workers should be faster and clearer
be assisted by his/her family.Based on this given in providing services to patients so that they feel
criteria, the total number of samples accepted comfortable with the attitudes held by health workers in
from the population was 95 respondents. Makassar City Hospital.
Table 1: Distribution of respondents scoring based on responsiveness dimension statements
Responses
Strongly Strongly
Statements Agree Disagree
agree disagree
n % n % n % n %
Doctors are fast and responsive in providing health services to
0 0 8 8.4 87 91.6 0 0
patients.
Doctors are willing to listen to the patient’s complaints. 0 0 10 10.5 85 89.5 0 0
Nurses inform quickly if there is a delay in providing health
4 4.2 36 37.9 55 57.9 0 0
services to patients.
Health workers always provide information on every action/
12 12.6 44 46.3 39 41.1 0 0
treatment that will be taken to the patient/family.
Nurses are fast and responsive in providing health services to
20 21.1 37 38.9 38 40.0 0 0
patients.
Health workers serve andaccept patients well. 0 0 40 42.1 55 57.9 0 0

Table 2 presented the distribution of respondents scoring based on assurance dimension statements. With
reference to the scoring on the description of the statement, the assurance on statement number one, there are 0%
strongly agree and disagree, 21.1% agree and 78.9% assessed disagree. For statement number two, there is 1
respondent who chose strongly agreed, 25 respondentsagreed, 69 respondents assessed disagreed and none rated
strongly disagreed. The third statement had 0 respondents who rated strongly agree, 20 respondents agree, 74
respondents disagree, and 1 respondent who strongly disagree. As for the fourth statement, 0% rate strongly agree
and disagree, 9.5% considered agree, and 90.5% assessed disagree. Likewise with the fourth statement, there were
no respondents who strongly agree or strongly disagree with the fifth statement. 30 respondents judged to agree and
65 respondents assessed disagree. For the sixth statement, 23 respondents rated strongly agree, 16 respondents
agreed, 56 respondents disagreed, and none strongly disagreed.

Table 2: Distribution of respondents scoring based on assurance dimension statements

Responses
Strongly Strongly
Statements Agree Disagree
agree disagree
n % n % n % n %
Doctor can always answer every question I asked. 0 0 20 21.1 75 78.9 0 0
Nurse is always polite and friendly towards patients. 1 1.1 25 26.3 69 72.6 0 0
Doctors did their duty well till patients feel satisfied and
0 0 20 21.1 74 77.9 1 1.1
comfortable in receiving care.
Nurse maintains confidentiality/privacy ofpatient’s
0 0 9 9.5 86 90.5 0 0
condition during treatment.
Doctors give attention to the complaints that patients feel. 0 0 30 31.6 65 68.4 0 0
Nurse is always available 24 hours if needed by the
23 24.2 16 16.8 56 58.9 0 0
patient.

The distribution of respondents scoring based on tangibility dimension statements is shown in Table 3. Based
on the description of the statements, the dimensions of physical evidence (tangible) on statement number 1, there
are 2 respondents who rated strongly agree, 44 respondents judged to agree, 49 respondents assessed disagree, and 0
respondents who rated strongly disagree. In statement number 2, 1.1% strongly agree, 34.7% agree, 64.2% disagree
and 0% strongly disagree. For the third statement, 28.4% agreed, 71.6% disagreed, and 0% strongly disagreed and
strongly agreed. As for the fourth statement, there are 4 respondents who rated strongly agree, 40 respondents agree,
51 respondents disagree, and 0 respondents who rated strongly disagree. Respondents neither voted for strongly
agree nor strongly disagree for the fifth statement. 21.1% considered agreeing while the remaining 78.9% assessed
disagreeing. For statement number 6, there are 2 respondents who rated strongly agree, 41 respondents agreed, 52
respondents (54.7%) assessed disagree, and nobody rated strongly disagree.

Table 3: Distribution of respondents scoring based on tangibility dimension statements

Responses
Strongly Strongly
Statements Agree Disagree
agree disagree
n % n % n % n %
Clean and attractive appearance of inpatient room. 2 2.1 4 46.3 9 51.6 0 0
Complete medical equipment is available (blood pressure
1 1.1 3 34.7 61 64.2 0 0
measurement device, stethoscope, infusion pole, etc.).
All health workers always neat and clean uniforms, as well use
0 0 7 28.4 68 71.6 0 0
identification/nametag.
Available facilities are reasonable at the price paid 4 4.2 0 42.1 1 53.7 0 0
Complete medicines are available at the pharmacy. 0 0 0 21.1 5 78.9 0 0
Complete health facilities are supported by sophisticated
2 2.1 1 43.2 2 54.7 0 0
technology.
Table 4 presented the relationship between the collection in the field showed there are some
dimensions and patients’ loyalty. Based on the respondents who judge poorly about the assurance
dimension of responsiveness, there were 33 respondents dimension because patients assume that nurses are
who considered good and loyalty or, and 33 respondents sometimes difficult to find if patients need services.
who are considered good but not loyal. While Therefore, health workers especially nurses need to pay
respondents who assessed the dimensions of more attention at any time if the patient needs service.
responsiveness were not good but loyal as many as 23 The obtained p value of
respondents and 6 respondents assessed the 0.000 proved there is a relationship between assurance
responsiveness dimension not good and not loyal. and loyalty of inpatients. This is in line with the research
Furthermore, the value of p conducted by Wandebori11, which stated that assurance
=0.007 means that there is a relationship between influences patients’ loyalty.
the dimensions of responsiveness and the loyalty of
inpatients.Research conducted by Ulfa9, and Sahara10 With reference to the tangibility dimension that,
stated that the responsiveness dimension has a positive those who assessed this dimensions as good and loyal
relationship with patients’ loyalty. This is supported byare as many as 41 people, while the good and non-loyal
the opinion of Ulfa9 where poor systems and processes are 29 people. Respondents who assessed the tangibility
greatly influence patients’ ratings even though hospitalsdimension as not good but loyal as many as 15 people,
have skilled employees since such as long waiting time whilethose judged poor and disloyal as many as 10
can cause hospitals to lose customers. respondents. This is due to the availability of complete
medicines at the pharmacy, health workers are always in
As for the dimensions of assurance, there are 65.9% neat uniforms, facilities are comparable to the payment
respondents who are good and loyal, while the good but especially in general patients. Nevertheless, most of
not loyal ones are 34.1%. 10 respondents valued the the respondents rated badly related to less clean and
assurance dimension as not good and are not loyal. unattractive inpatient rooms, incomplete facilities such
There are health workers, especially doctors and as air conditioner not functioning, fan was not available,
nurses who are able to answer every question posed by and the patient complained and felt hot in the room, the
the patient, the doctor is on duty so that the patient X-ray instrument was not available so the patient used
feels satisfied in receiving treatments. However, the X-rays outside of Makassar City General Hospital.
results of data Therefore,
the hospital is supposed to be remodeling properly and the loyalty of inpatients. The results of this study are in
completing each room accordingly with patients’ needs. accordance with the research conducted by Diniaty12 at
Moreover, since the p value= 0.901, there is no the RSUD TengkuRafi’anKabupatenSiakwhich stated
significant relationship between the dimensions of that tangibility affect patients’ loyalty.
tangible with

Table 4: Relationship between responsiveness dimensions and patients’ loyalty

Patients’ loyalty Total
Dimension Loyal Not loyal p
n %
n % n %
Good 33 50.0 33 50.0 66 69.5
Responsiveness Poor 23 79.3 6 20.7 29 30.5 0.007
Total 56 58.9 39 41.1 95 100
Good 56 65.9 29 34.1 85 89.5
Assurance Poor 0 0 10 100.0 10 10.5 0.000
Total 56 58.9 39 41.1 95 100
Good 41 58.6 29 41.4 70 73.7
Tangibility Poor 15 60.0 10 40.0 25 26.3 0.901
Total 56 58.9 39 41.1 95 100
Conclusion REFERENCES

From the results of research conducted at Makassar 1. Damayanti NA, Jati SP, Fatmasari EY.
City Public Hospital about the relationship between the Differential level analysis of satisfaction with
the coverage of Nursing Services for Public
quality of health services and the loyalty of inpatients, it
Health Insurance Status and Plenary in
can be summarized as follows:
Semarang City. Journal of Community Health
1. There is a relationship between the dimensions of (e-Journal). 2018 Oct
responsiveness, and assurance with the loyalty of 1;6(5):124-34.
inpatients at Makassar City Hospital. 2. MaulanaIS, Amalia N. The Relationship of 5
2. There is no relationship between the dimensions Dimensions of Service Quality with Loyalty to
Patients in the Inpatient Installation of Samarinda
of tangibility with the loyalty of inpatients at
Medika Citra Hospital in Year 2018.
Makassar City Hospital.
3. Supriyanto S, Ernawati M. Industrial Marketing
Acknowledgement Health Services. Edited by O. HS. Yogyakarta:
Andi. 2010.
The authors are thankful to Faculty of Community 4. Gunawan K, Djati SP. Service Quality and Patient
Health, Hasanuddin University for their support and Loyalty (Study at the Hospital of Private Public in
facilities in conducting this study. The authors would Singaraja City, Bali). Journal of Management and
also like to express their gratitude towards all the Entrepreneurship. 2011 Sep 30;13(1):32-9.
respondents (patients) from RSUD Makassar City who
5. Mahamad O, Ramayah T. Service quality,
was willing to participate in this study. customer satisfaction and loyalty: A test of
mediation. International business research. 2010
Ethical Clearance: Taken from the committee
Oct 1;3(4):72.
Source of Funding: Nil 6. Asmita W. Analysis of the Influence of Patient
Perception About Mutu ServicesDoctor Against
Conflict of Interest: Nil
Patient Loyalty at the Polyclinic General
Installation Care for Hospital Hospital Semarang 10. Sahara N. Analysis of the Influence of Satisfaction
Hospital in 2008. (Doctoral dissertation, Post- on Service Services for Doctors against Interests
Ceremony Program Diponegoro University). Visit (Study in Patients General in Hospital
7. Berlianty A. Nurhayani. Analysis of Patient Installation in RSUD A Dadi Tjokrodipo Bandar
Loyalty based on Quality of Service at Inpatient Lampung). Journal of Medical Sciences and
Installation in Bhayangkara Hospital, Makassar, Health. 2016;3(2).
Makassar City in 2013. Journal of Public Health. 11. Wandebori H. Revisit Intention to Hospital:
2014. Factors Unveiled From a Case Study of Balimed
8. Hidayah TN. Satisfaction of Non PBI BPJS Hospital. Journal of Theory and Applied
Patients Against Service Quality for First- Management. 2017 Dec 21;10(3):205-16.
Level Providers of Family Doctors in 12. Diniaty D. Analysis of Quality at the Service of
Laweyan Subdistrict, Surakarta Municipality Community Satisfaction or Patients in Tengku
(Muhammadiyah University of Surakarta). Rafi Hospital, Regency of Siak Using Method
9. Ulfa R. Relationship Characteristics of Patients, Importance Performance Analysis and Potential
Quality of Service and Inhibition of Moving with Gain in Customer Value. JTI: Journal of Industrial
Patient Loyalty in Nursing Installation Road Engineering. 2016 Jun 1;2(1):25-30.
Hospital Hospital Depok in 2011. University of
Indonesia. Jakarta. 2012.
DOI Number: 10.5958/0976-5506.2019.01720.0

Relationship of Marketing Mix with Loyalty of Patients of

Dental Poly in BatuaPuskesmas, Makassar City in Year 2016

Suciana Aprilia Angraeni1, Nurhayani1, H. AmranRazak1

1
Department of Administration & Health Policy, Faculty of Community Health, University of Hasanuddin,
Makassar, Indonesia

ABSTRACT
This study aimed to determine the relationship between marketing mix and the patients’ loyalty of Poly
Dental in BatuaPuskesmas Makassar City using quantitative study with a cross sectional design. The total
population of this study was 190 respondents which were taken using the accidental sampling method.
The results showed that the variables related to the marketing mix with the loyalty of the dental polyclinic
patients at BatuaPuskesmas were products (p = 0.00), place (p = 0.039), health workers (p = 0.00), process
(p
= 0.00), physical facilities (p = 0.00), promotions (p = 0.006). Whereas the unrelated variable was price (p
=
0.076). The dental polyclinic at BatuaPuskesmas is expected to further improve the marketing mix process,
although it is good enough but must continue to pay attention to the service process in terms of the time that
the patient sometimes have to wait long.

Keywords: Marketing Mix, BatuaPuskesmas, Loyalty, dental polyclinic and patients.

Introduction satisfaction which will ultimately increase consumers’
loyalty4.
Oral and dental health is one of the supporting
aspects of a healthy paradigm and is a national
development strategy to realize healthy Indonesia 2010.
56.7% health centres in Indonesia have carried out
community dental health business, while 86% of health
centre in Indonesia have implemented the School Dental
Health Business1.

The description of the service utilization of the

health centre dental polyclinic can be seen based on the
number of visits by the people who get dental treatment
per day. Situmorang2’s study showed that out of 360
respondents, it was found that only 10% had ever
undergone dental treatment for health services at health
centres. This indicated that high dental and oral
diseases have not been matched by the utilization of
health service units3.

Marketing mix can be used as a marketing tool

that makes it easier for health centres to achieve their
marketing goals. Along with the times, marketing mix has
also developed. This is seen from the magnitude of the
influence of the direct relationship between the
components in marketing mix (products, tariffs, places,
promotions, people, processes, and physical facilities).
Marketing mixprogram has a very important role as part
of the strategy and company policy to realize customers’
In this globalization era, the social condition of
society is increasing where the public is increasingly
aware of the quality, it is necessary to improve the quality
of satisfaction-oriented health services so that patients
will feel loyal to the provision of health services.
Hawkins et al.5 researched on dental and oral hygiene
measured using the Oral Hygiene Index Simplified
(OHIS) showed that the average dental and oral hygiene
of elementary school students in grade IV - VI in the
specific district of Jakarta area was in the moderate
category of 53.8% of the students who have been
examined. Maharani6’s research results showed that
88.3% of respondents had dental and oral hygiene status
in the unclean category, only 11.7% of respondents had
dental hygiene status in the clean category. This problem
needs to be addressed since dental and oral hygiene is a
very decisive factor in the process of maintaining oral
health.

The results of the research conducted by Hayati et

al. revealed that there is a there is no significant relation
7

between place mix and physical proof mix with patients’

loyalty, but there is significant relation between product
mix, price mix, promotion mix, and process mix with
patients’ loyalty. Based on research done by Semboret
at.8 about marketing mixrelationship with patients’
loyalty, it was concluded that there was no relationship
1057 Indian Journal of Public Health
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Journal &
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Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1057

between the product service marketing mix and patient The populations in this study were all patients who
loyalty, whereas there was a relationship between the had dental examinations at the BatuaPuskesmas. The
marketing mix of price, place, promotion, staff (people), number of patients in 2016 was 74565 patients with
process, physical evidence and facility services with an average of 15 patients per day multiplied by 25
patients’ loyalty. A similar study was conducted by working days in dental polyclinic. Hence, there are 375
Riana9 which also proved that there was a relationship patients per month. The samples in this study were poly
dental patients who were encountered during the study.
between products, promotions, processes, and physical
The sampling procedure used the accidental sampling
facilities with the utilization of services in the Sanrobone
method, which is randomly taken by respondents or
Health Centre dental clinic. at the time of the research. Therefore, the number of
samples in this study was 100 samples.
From the data collection at BatuaPuskesmas, an
overview of patient visits per day to the dental in Data sources from this study were obtained from
average was 15/day and seen from patient’s visits written documents/data on visits of poly dental patients
from 2013- at BatuaPuskesmas. The gathered data were analyzed
2015, it was known that each year the dental poly patient using the SPSS program for univariate analysis and
visits increase10. bivariate analysis. The research variable consisted of
seven independent variables, the marketing mix, namely
Based on the description above and in improving product, price, place, promotion, people, process and
health services and the benefits obtained by the company physical evidence, while the dependent variable was
if it has loyal customers, it is very important for the patients’ loyalty.
BatuaPuskesmas to have the right marketing strategy,
with marketing programs that can be done to improve Result and Discussion
service quality. Therefore, to see whether marketing
Univariate Analysis: The distribution of respondents
programs have been carried out effectively, it is
rating based on the product marketing mix (type of
necessary to conduct research to determine the service) in BatuaPuskesmasis shown in Table 1. Based
relationship between marketing mix and patients’ loyalty on the statement of dental poly products, 81 respondents
to dental polyclinic at BatuaPuskesmas. gave answers strongly agree that the equipment used in
dental poly is feasible to use. It can be concluded that
Methodology the respondents who gave the most answers strongly
agreed that examinations by doctors in dental poly were
This research is a quantitative research in the in accordance with the needs of patients with a
form of a survey with cross sectional approach where percentage of 83.0%, 19.0% disagreed that the
the independent variables and dependent variables medicines needed by patients are available, while
are examined simultaneously in the same period. respondents who answered strongly disagreed that
The quantitative approach is done by collecting and medicines needed by patients are provided with a total
of 19 respondents. In addition,
processing data to find accurate facts and precise as well
6.0% strongly agreed that the services provided in
as systematic interpretations regarding the marketing
BatuaPuskesmas covered a wide range of services.
mixrelationship with the loyalty of poly dental patients Although 4 respondents strongly disagreed that the
in BatuaPuskesmas.This research was carried out at the nurses provided services in accordance to the patients’
Dental Clinic of BatuaPuskesmas for a month from the need, a majority of 84 respondents, strongly agreed with
27th March-27th April 2017. this statement.

Table 1: Distribution of respondents based on ‘product’ variable statements

Strongly Strongly
Statements Agree Disagree
agree disagree
Services in dental polyclinic in BatuaPuskesmas are diversifying. 86 6 4 4
Examination by dentists in dental polyclinic is in accordance with
83 5 8 4
the patient’s needs.
Nurse services in dental polyclinic are in accordance with patient needs. 84 9 3 4
The health inspection equipment used is assorted. 88 6 2 4
Conted…
Equipment used in dental poly is suitable for use. 81 9 5 5
Medications needed by patients are available. 57 12 12 19

Table 2 presented the distribution of respondents rating based on the price in BatuaPukesmas of Makassar city.
Based on the statements of dental poly prices, 93 respondents gave a very agreeable answer that the details of the
services cost in of the clinic was clear. While 94 respondents who strongly agreed that the payment method was
easy and uncomplicated. Statement number two till number four had the same number of responses from the
respondents. Majority of the respondents strongly agreed with these statements: information on examination ratesare
given by the officer, affordable examination rates, and expenditures are proportional to the services.

Table 2: Distribution of respondents based on ‘price’ variable statements

Strongly Strongly
Statements Agree Disagree
agree disagree
The payment method is easy and not complicated. 94 0 5 1
Information on examination rates are given by the officer. 90 4 6 0
Affordable examination rates. 90 4 6 0
Expenditures are proportional to the services. 90 4 6 0
Cost details are clear at dental poly services. 93 0 7 0

Table 3 presented the distribution of respondents based on the people marketing mix (health workers) in the
BatuaPuskesmas. Based on poly dental statements, 92 respondents (48.4%) gave answers strongly agree that doctors
and dental nursesskilfully used medical devices. Whereas respondents gave the least answers for strongly agreed,
was for the statement ‘the doctors and nurses in the dental clinic examined patients carefully’ which was voted by
only 40 respondents. Among the eight statements, statement number two was highly agreed by most of the
respondent with
85.0% strongly agree and only 15.0% opposed this statement.

Table 3: Distribution of respondents based on ‘people’ variable statements

Strongly Strongly
Statements Agree Disagree
agree disagree
Doctors and dental nurses are skilled at using medical devices 72 6 21 1
Service to all patients regardless of social status 85 0 5 10
Doctors and nurses examine patients carefully 40 32 20 8
Doctors and nurses pay attention to patients’ complaints during examination 47 31 17 5
Doctors and nurses provide solutions to patients after being examined 46 33 15 6
Doctors and nurses provide good answers when patients ask 48 30 16 6
Doctors and nurses provide friendly and caring services 47 26 18 9
Doctors and nurses at the Batua Health Centre Dental Polyclinic look
41 31 20 8
neat at work
Bivariate Analysis: Table 4 showed that of the 100 was unacceptable and were not loyal as many
respondents who have been interviewed, it is known as
that 61 respondents said that on the context of ‘product’ 13respondents. Furthermore, the results of the Chi-
it was acceptable and loyal whereas those who agreed square test between variables obtained that there is a
that the ‘product’ was acceptable but not loyal were relationship between product and the loyalty of dental
11respondents (11.0%). Respondents who said the poly patients with a value of p = 0.000. Based on the
product was unacceptable but loyal, were as many results of the study, it can be concluded that the better
as 15 respondents and those who said the ‘product’ the product, the more loyal the patients would be
towards the health centre. This is in accordance with the
research
by Husada11 in Massenrempulu General Hospital, Kab. Table 6 presented the relationship between people
Enrekang which agreed that there is a relationship and loyalty. Based on the table, it is known that
between product and patient loyalty in the inpatient unit, respondents who said that health workers were
but it is different from the research conducted by Ika12 acceptable and loyal, were 61 respondents whereas
in the outpatient polyclinic of Kediri Baptist Hospital acceptable but not loyal were 11 respondents. 15
which stated that there is no relationship between patient respondents found it unacceptable yet they were loyal.
perceptions of products and patient loyalty. Unlike the 13 respondents who said it was
unacceptable and were not loyal. Chi-square test results
Table 4: Relationship between products with loyalty between variables showed that there is a relationship
between the people (health workers) and the loyalty of
Patients’ loyalty dental poly patients with a value of p = 0.000. This
Total
Product Loyal Not loyal p-value study is in accordance with the research by Sembor et
(n)
(n) (n) al.8 at Siloam Manado hospital, who reported that there
Acceptable 61 11 72 was a relationship between staffs and patients’ loyalty.
Unacceptable 15 13 28 0.000 Moreover, their study stated that among the other
Total 76 24 100 factors (product, price, place, promotion, process,
physical evidence and facility services), staff was the
The relationship between price and loyalty is most dominant factor influencing the patients’ loyalty.
presented in Table 5. Based on Table 5, it was known
that respondents who said that the price was acceptable Table 6: Relationship between people with loyalty
and loyal were 53 respondentswhile 24 respondents said
Patients’ loyalty
it was acceptable but not loyal. Respondents who said Total
People Loyal Not p-value
the prices were unacceptable but loyal were as many (n)
(n) loyal (n)
as 12 respondents and those who said the prices were
Acceptable 61 11 72
unacceptable and not loyal as many as 11 respondents.
Unacceptable 15 13 28 0.000
The results of the Chi-square test obtained a p-value
Total 76 24 100
of 0.076 which signified that there is no relationship
between the price and loyalty of dental poly patients.
This is consistent with the research conducted by Conclusion
Toding at Elim Makassar Hospital which also proved
13
Based on the results of the research and discussion
that there is no relationship between the tariff strategy
described regarding the marketing mix with the loyalty
and the interest in returning inpatients. However, it was
of the dental poly patients in BatuaPuskesmas of
different from the research conducted by Yuliantine et
Makassar, the following conclusions can be drawn:
al.14 who reported that there was a relationship between
rates/prices and patients’ loyalty in the inpatient hospital 1. There is a relationship between product and
of Muhammadiyah. In general, the consideration of a people with the loyalty of poly dental patients at
given price is generally influenced by one’s work and BatuaPuskesmas, Makassar City
socio-economic status. The better the person’s job, the 2. There is no relationship between price and the
better the socio-economic status will be. loyalty of poly dental patients at Batua Health
Centre, Makassar City.
Table 5: Relationship between prices with loyalty
Acknowledgement
Patients’ loyalty
Total The authors are thankful to Faculty of Community
Price Loyal Not p-value
(n) Health, Hasanuddin University for their support and
(n) loyal (n)
Acceptable 53 24 77 facilities in conducting this study. The authors would
also like to express their gratitude towards all the
Unacceptable 12 11 23 0.076
respondents (patients) of Dental Poly in
Total 65 35 100
BatuaPuskesmaswho was willing to participate in this
study.
Ethical Clearance: Taken from the committee to patients in Nursing Homes Hospitals in Kalisat
District, Jember Regency 2017.IKESMA. 2018
Source of Funding: Nil
Mar 19;14(1):45-56.
Conflict of Interest: Nil 8. Sembor PE, Posangi J, Kaunang WP. The
relationship between patients is general about the
REFERENCES marketing mix with loyalty of patients in Siloam
Manado Hospital care unit. TumouTou.
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2015;1(1).
Children Aged 7 to 12 Years About Oral Hygiene
Based on the Characteristics of SDN JalanAnyar 9. Riana. Relationship between market mix with the
Kota Bandung (Doctoral dissertation, Universitas utilization of dental polyclinic services in coastal
Pendidikan Indonesia). areas working area of S anrobone Public Health
Center, District of 2014. (Thesis, Hasanuddin
2. Situmorang N. Behavior Searching Medication
University).
and Health Care Visiting Dental Clinics in the
Two Districts of Medan City, Dentika. Dentika 10. Puskesmas 2013-2015b. Profile of Batua Health
Dental Journal. 2004;10(1). Center in 2015. Makassar: Batua Health Center.
3. Jin LJ, Lamster IB, Greenspan JS, Pitts NB, 11. Husada SK. Relationship between nurses’ caring
Scully C, Warnakulasuriya S. Global burden of attitude towards the implementation of oral
oral diseases: emerging concepts, management hygiene in the Intensive Room of Dr.Moewardi
and interplay with systemic health. Oral diseases. Hospital Surakarta.
2016 Oct;22(7):609-19.
12. IkaSHPD. Analysis on the influence of Patients
4. Rowley J. Information marketing. Routledge; Perception about Marketing Mix on Patients
2016 May 23. Loyalty at the Outpatient Clinic of Baptist Hospital
5. Hawkins RJ, Zanetti DL, Main PA, Jokovic A, in Kediri (Doctoral dissertation, MIKM UNDIP).
Dwyer JJ, Otchere DF, Locker D. Oral 13. Toding, E. Relationship to Marketing Variations
hygiene with Interest in Returning Nursing Patients at
knowledge of high‐risk Grade One children: Elim Makassar Hospital. (Thesis, Hasanuddin
an evaluation of two methods of dental health University).
education. Community dentistry and oral
14. Yuliantine T, Indasah I, Siyoto S. Analysis of
epidemiology. 2000 Oct;28(5):336-43.
Marketing Mix Characteristics of Marketing
6. Maharani DA. Do the Indonesians receive the Factor 7P (Product, Price, Place, Promotion,
dental care treatment they need? A secondary People, Process, Physical Building) to Patient
analysis on self-perceived dental care need. ISRN Satisfaction of Inpatient Patient Hospital
dentistry. 2012 Jul 19;2012. Muhammadiyah Ahmad Dahlan Kediri City.
7. Hayati YS, Sandra C, Herawati YT. Relationship Journal for Quality in Public Health. 2018
between the contribution of marketers and loyalty May
11;1(2):50-7.
DOI Number: 10.5958/0976-5506.2019.01721.2

Relationship of Marketing Mix with Return of Outpatients’

Interest at Dr.TadjuddinChalid Specialist Hospital, Makassar
in 2017

YustiamkaPermana1, H. Indar1, Nurhayani1

1
Department of Administration &Health Policy, Faculty of Community Health, University of Hasanuddin,
Makassar, Indonesia

ABSTRACT
This quantitative study with a cross sectional approach aimed to determine the mix marketing relationship
with interest in returning of outpatients to Dr.TadjuddinChalid Specialist Hospital, Makassar in 2017. The
population was 8756 patients, taking 95 samples with non-probability sampling techniques. Data collection
was done by interviewing using questionnaire. The collected data were analyzed using the Chi-square
test. The results showed that there was a relationship between product (p = 0.000), price (p = 0.002), and
people (p = 0.043). However, there is no relationship between place (p = 0.229) with interest in returning of
outpatients. Based on the results, this study suggested some improvements to the overall supporting
facilities in accordance to the patients’ needs such as ATM machines, photo copy machines as well as make
brochures to promote hospital services.

Keywords: Marketing Mix, Dr.TadjuddinChalid, Specialist Hospital and

Outpatients.
Introduction be said that the reputation of the hospital depends on its
first service.
Hospital is a health service institution that organizes
individual health services in a comprehensive manner Dr.TadjuddinChalid Specialist Hospital Makassar
that provides inpatient, outpatient and emergency City which was established in 1980 does have the
services. Hospitals not only function to provide medical outpatient services. Along with the continuous increase
services but also provide nursing services and care in number of hospitals in the province of South
activities, medical support services and non-medical, Sulawesi, it is crucial for Dr.TadjuddinChalid
public health services and education1. In Indonesia, Specialist Hospital to improve the overall quality of
public hospitals are hospitals managed by the health services. It needs to buff up the marketing
government, regional government, or non-profit legal strategy in making the hospital a choice among
entities whereas private hospitals are managed by a consumers. The most universal and widely developed
legal entity with the aim of profit in the form of a marketing concept is the marketingmix. It is a set of
limited liability company. In 2015, marketing tools used by companies to continuously
2488 hospitals in Indonesia were divided into public achieve marketing objectives in the targeted market.
hospitals and private hospitals. This showed a significant
increase in the previous two years, which were 2228 and To introduce the product or service offered, hospital
2406 respectively. In South Sulawesi alone, the increase needs to carry out several promotional combination
occurred in both public hospitals and private hospitals, alternatives which are part of the marketingmix;
which was from 76 units in 2013 to 81 units in 20142. personal sales, advertising, word of mouth, sales
promotion, public relations, and direct marketing3.
Outpatient service is part of medical services Hospitals must be able to adjust between the
that gives first impressions to patients as consumers. marketingmix with the needs and desires of consumers,
Outpatient services are also a place of transition for because by giving more satisfaction to consumers
patients who come to the hospital to be hospitalized. The compared to other competitors, then it can attract
image of the hospital is contested herein, so that it more consumers. Satisfaction and dissatisfaction of
can consumers will influence the interest
1062 Indian Journal of Public Health
IndianResearch
Journal &
of Development,
Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1062

to return. If the patient is satisfied, he/she will show The population in this study was patients from
a higher probability of repurchasing the product or 13 polyclinics that seek outpatient treatment at Dr.
service. Satisfied customers also tend to tell good TadjuddinChalid Specialist Hospital with yearly average
things about the products or services they receive to of 8756 patients. The sampling technique used in this
others. Unsatisfied consumers act in reverse. They may study was carried out by non-probability sampling,
take public actions, such as filing complaints against namely the technique of incidental sampling whereby
hospitals, going to lawyers, or complaining to other the sample coincidently exists at the time of the research
groups (such as business entities, the private sector, or and meets the criteria for research sample. The
the government). Personal actions can be in the form of respondents of this research are those who qualified as
deciding not to use the product or service4. follows:

The results of study by Setianingsih5 showed a a. Respondents are patients who have more than two
significant relationship between products (services) visits.
to patient loyalty with p value = 0.025. Whereas the b. Respondents are able to understand the questions
perceptions of other marketing mixes such as location, contained in the questionnaire and answer the
promotion, price, people, physical evidence, and question itself whereas for respondents who have
processes do not show a significant relationship in difficulty completing the questionnaire, they can
her study.Another study on marketing mix relations be assisted by his/her family.
with loyalty among patients at Siti Khadijah Hospital
Makassar City showed that there was a relationship of Based on this given criteria, the total number
promotion with patient loyalty with a value of p = 0.008, of samples accepted from the population was 95
there was a relationship between physical facilities and respondents.
patient loyalty with a value of p = 0.000,there was a
The primary data are obtained through a list of
relationship between the process and patient loyalty with
questions (questionnaires) that have been prepared
a value of p = 0.000. However, there was no relationship previously and distributed to respondents. Meanwhile,
between service providers and patient loyalty with a the secondary data are obtained from document
value of p = 0.078. Thus, it can be concluded that there collection such as annual report and profile of Dr.
is a relationship between promotion, physical facilities, TadjuddinChalid Specialist Hospital, and other sources
and processes with patients’ loyalty6. related to research. The data collected from
In order to improve health services and maintain a questionnaires are tabulated in a master table and
analyzed using SPSS program which consisted of
number of visits, a better marketing strategy is needed
univariate and bivariate analysis.
which will later influence the decisions of patients in
using hospital services. Therefore, the researchers of
this study are interested in researching “relationship Result and Discussion
of marketing mix with return of outpatients’ interest at
Univariate Analysis: Table 1 presented the distribution
Dr.TadjuddinChalid Specialist Hospital, Makassar” for of respondents’ evaluation based on product (type of
the year of 2017. service), price, place and people (staffs) provided to
outpatients by Dr. TadjuddinChalid Specialist Hospital
Methodology Makassar City.

The type of research used is quantitative research The respondents’ assessment of products(type
which is an observational analytic with cross sectional of services) can be measured through five elements
approach. It is meant to know the relationship between consisting of a variety of health equipment used,
marketing mix relations with returns of outpatients’ at completeness of health equipment, services provided by
Dr. TadjuddinChalid Specialist Hospital Makassar City. health workers according to patient needs, availability of
The research was conducted at Dr. TadjuddinChalid medicines and availability of supporting services such
Specialist Hospital’s outpatient services from as laboratories, radiology etc. Based on Table 1, it was
February shown that 89 respondents (93.7%) felt that the products
2017 to March 2017. available are quite good whereas 6 respondents (6.3%)
showed disagreement.
The respondent’s assessment on price of outpatient outpatient services. As shown in Table 1, 54 respondents
services provided is measured based on whether the (56.8%) agreed that Dr. TadjuddinChalid Specialist
service rates are affordable or the service rates are in Hospital is easily reachable while total of 41 respondents
line with the services received by respondents. Under (43.2%) faced difficulty to reach the hospital.
price category,out of 95 respondents, there were 91
respondents (95.8%) who assessed the price charged Assessment from respondents’ of health workers
for outpatient services was quite reasonable in the outpatient facility are measured based on good
while communication between patient and doctor, clean and
4 respondents (4.2%) felt that the price is not worth neat appearance, polite and friendly health workers,
comparing to the available services. highly skilled in using medical devices and keen to
hear patients complaints. 93 respondents (97.9%)
Factors such as location easily accessible through rated satisfactory in outpatient services found in
personal or public transportation distance of residence Dr.TadjuddinChalid Specialist Hospital Makassar City.
close to the hospital location and easy to find a basic In contrast, only 2 respondents (2.1%) felt dissatisfied.
amenity influences the respondent’s assessment to seek
for

Table 1: Distribution of respondents’ evaluation based on product (type of service), price, place and people
(staffs) provided to outpatients by Dr. TadjuddinChalid Specialist Hospital Makassar City
Category Frequency (n) Percentage (%)
Good 89 93.7
Product (type of service)
Poor 6 6.3
Reasonable 91 95.8
Price
Unreasonable 4 4.2
Reachable 54 56.8
Place
Not reachable 41 43.2
Good 93 97.9
Staffs
Poor 2 2.1
Bivariate Analysis: The results of the bivariate analysis results of statistical tests using the Chi-square test show
between the relationships of product, price, place and that there is a relationship between the product and the
people (staffs)with outpatients’ interest to return at Dr. interest in returning outpatients where the value of
TadjuddinChalid Specialist Hospital Makassar City are p
tabulated as in Table 2. = 0.000.This is in line with the research conducted by
Hidayat7, that product influenced the service utilization
It shows that of all respondents who rated the
decisions in Hasanuddin University Hospital Makassar
product (type of service) as good, there were 75
in 2014 where the value of p = 0.006. Whereas, Akbar
respondents (84.3%) expressed interest and as many
et al.8 suggested that the product is related to the
as 14 respondents (15.7%) expressed no interest.
patient’s decision to choose health services. The better
Respondents are not interested in returning to use the
the products of the hospital, more patients will choose
service because it is influenced by other factors such as
health services at that particular hospital.
distance from the patient’s home to the hospital. While
respondents who stated that the product (type of service) In terms of price, it shows that from all respondents
was not good, 0 respondents expressed interest to return who rated the price (service tariff) as reasonable, 75
and as many as 6 respondents expressed no interest to people (82.4%) expressed interest to return while 16
return. This is because the medicines needed by patients people (17.6%) did not want to seek treatment again at
are sometimes not available and needs to be purchased this hospital. This could be due to lack of basic
outside the hospital.If the respondent’s assessment is amenities surrounding the hospital. There were 4 people
not good for the product/type of service, the respondent (100.0%) who felt the price is unreasonable and has no
will feel dissatisfied. Dissatisfaction of respondents interest to return. This is due to the overall service
can cause respondents to move to other hospitals. rates charged by the hospital is not in accordance with
The
the obtained services. The results of the analysis of the
price (service
tariff) relationship with the return interest of patients reach, they are still interested in using again the
who use outpatient services at Dr. TadjuddinChalid outpatient services due to hospital staff being friendly
Specialist Hospital in Makassar using Chi-squared and good at providing patients with explanations of the
statistical tests obtained p = 0.002 which means that disease. From the table also obtained p = 0.229. This
there is a relationship between price (service rates) and concludes that there is no relationship between the place
return interest in patients. The results of this study are and the interest in returning outpatients at
in agreement with the research conducted by Syafar et Dr.TadjuddinChalid Specialist Hospital in Makassar.
al.9 who stated that there was a relationship between The result is accordance to research by Akbar et al.8
price and the interests of returning patients to Hospital who showed that there is no significant connection
of Hasanuddin University. Nonetheless, the results of between place and the decision to choose health
this study are not in line with the research conducted by services.
Setianingsih5 which stated that there is no relationship
between the price and the interest in returning of Based on Table 2, it shows that all respondents that
outpatients in Dr. Sitanala Tangerang Hospital. rated people (health workers) as good, 75 respondents
(80.6%) expressed interest to return again and 18
An overview of the results of the bivariate analysis respondents (19.4%) expressed no interest. While
between the relationship of place and interest in respondents who stated people (health workers) were
returning outpatients is shown that the total respondents not good and have no interest to return as outpatients,
that agreed the location of hospital are easy to reach and are 2 respondents (100.0%). The results of the analysis
interested to return are 45 respondents (83.3%) while 9 of the people (health workers) relationship with the
respondents (16.7%) felt the otherwise. This shows that return interest of patients who used outpatient services
the location of the hospital is quite strategic and easy to at Dr.TadjuddinChalid Specialist Hospital in Makassar
reach. This is in accordance with the theory by Steiber using Chi-squared statistical tests obtained p = 0.043.
and Boscari in Hidayat7 whereby important reason for This means that there is a relationship between people
choosing the hospital is the location. Respondents who (health workers) and return interest in patients. This
stated that the place (service location) is not as good but research is in line with the research conducted by Indar
expressed their interest to seek again treatment as many et al.10 that there is a relationship between people and
as 30 people (73.2%) whereas 11 respondents (26.8%) the decision to choose health services at Faisal Makassar
expressed no interest to return. This demonstrated that Islamic Hospital. Widajat11 suggested that attitude of
even though respondents rated the place is difficult health workers when serving patients also plays vital
to role in influencing patient’s decision to return again.

Table 2: Relationship between productprice, place, and people (staffs)with outpatient’s interest to return

Outpatients’ interest to return Total

Category Interested Not Interested p
n %
n % n %
Good 75 84.3 14 15.7 89 93.7
Product Poor 0 0 6 100 6 6.3 0.000
Total 75 78.9 20 21.1 95 100
Reasonable 75 82.4 16 17.6 91 95.8
Price Unreasonable 0 0 4 100 4 4.2 0.002
Total 75 78.9 20 21.1 95 100
Reachable 45 83.3 9 16.7 54 56.8
Place Not Reachable 30 73.2 11 26.8 41 43.2 0.229
Total 75 78.9 20 21.1 95 100
Good 75 80.6 18 19.4 93 97.9
People Poor 0 0 2 100 2 2.1 0.043
Total 75 78.9 20 21.1 95 100
Conclusion 4. Vogus TJ, McClelland LE. When the customer
is the patient: Lessons from healthcare research
From the results of research conducted at Dr.
on patient satisfaction and service quality ratings.
TadjuddinChalid Specialist Hospital Makassar City
Human Resource Management Review. 2016 Mar
about the relationship between the mix marketing and
1;26(1):37-49.
outpatients’ interest to return, it can be summarized as
follows: 5. Setianingsih A. Relationship between Market
Marketing and Customer Service with Patient
1. There is a relationship between the product (type
Loyalty. Journal of Community Health Sciences.
of service), price, and people with the interest in
2018 Mar 20;7(01):51-62.
returning outpatients.
6. Maulinda, K. Relationship between Market
2. There is no relationship between the place
Mixing and Patient Loyalty in the Nursing Room
with
of the Hospital and Child Sitti Khadijah City
the interest in returning outpatients.
Makassar (dissertation, Hasanuddin University).

Acknowledgement 7. Hidayat, L. Analysis of the Effect of Market

Variations on the Decision of Utilization
The authors are thankful to Faculty of Community of Outpatient Installation in Rumah Sakit
Health, Hasanuddin University for their support and Hasanuddin University Makassar in 2014 (thesis,
facilities in conducting this study. The authors would Hasanuddin University)
also like to express their gratitude towards all the
8. Akbar AI, Darmawansyah&Hamzah A.
respondents (patients) from Dr. TadjuddinChalid
Relationship to Marketing Sharing with Decisions
Specialist Hospital who was willing to participate in this
Choosing Health Services in Inpatient Patients
study.
in Hospitals and Children of Fatimah Makassar
Ethical Clearance: Taken from the committee in 2012. Journal of Administration and Health
Policy. 2013.
Source of Funding: Nil
9. Syafar M, Hamzah A, Amelia R. Effect of Market
Conflict of Interest: Nil Variability on Patient Loyalty in Nursing in
Rumah Sakit Hospital Hasanuddin Makassar
REFERENCES 2013. Journal of Administration and Health
Policy 2014;3(01).
1. Meesala A, Paul J. Service quality, consumer
satisfaction and loyalty in hospitals: Thinking 10. Indar I, Hamzah A, Nurlia C. Relation of
for the future. Journal of Retailing and Consumer Marketing Mix with Decision Choosing Health
Services. 2018 Jan 1;40:261-9. Service Inpatient Unit of Faisal Islamic Hospital
Makassar 2011. Journal of Administration and
2. RI Health. 2014 Data and Information (Indonesian Health Policy Indonesia. 2012;1(1).
Health Profile). Jakarta: Republic of Indonesia
Ministry of Health Indonesia. 2015. 11. Widajat R. Being a great and sustainable hospital.
Gramedia Main Library; 2013 Jan 15.
3. Hosseini SM, Etesaminia S, Jafari M. Identifying
eleven factors of service marketing Mix (4Ps)
effective on tendency of patients toward
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DOI Number: 10.5958/0976-5506.2019.01722.4

The Factors Related to Work Fatigue of Block Paving Workers

at CV. SumberGalian in 2017

Putri Yanti1, Andi Wahyuni1, Awaluddin1

1
Department of Work Safety and Health, Faculty of Community Health, University of
Hasanuddin, Makassar, Indonesia

ABSTRACT
Block paving workers play an important role in CV. SumberGalian with various tasks that require moderate
to high work activities and they have to make as many as 600 blocks per day. This can cause workers to
experience fatigue easily. Thus, this observational analytic with cross sectional approach research, aimed
to determine the relationship of work stress, energy intake, work period and haemoglobin level with work
fatigue in block paving workers in CV. SumberGalian, Makassar City in 2017. The total number of samples
was 40 people, taken by exhaustive technique sampling. Data were taken from respondents using the
Reaction Timer questionnaire to measure the work fatigue and Nutri Survey and food recall to obtain
energy intake data. The data are then analysed using Chi-square test and logistic regression. The results
showed that there was a relationship between work stress p = 0.002, energy intake p = 0.005, work period
p= 0.028 with work fatigue among block paving workers at CV. SumberGalian. The most influential
variable in this study was work stress.

Keywords: SumberGalian, Block paving workers, CV and Work

Fatigue.
Introduction From the data of research conducted by Putra et
al.5, it can be seen that work fatigue experienced by
Work exhaustion is a phenomenon that is often
reinforcement production workers is in light work
experienced by workers, but this cannot be ignored fatigue of 14 people (58.3%) and moderate work fatigue
because it relates to the protection of labors’ health. It of 10 people (41.7%). According to the results of
is stated that of 80% of human errors, 50% are caused research conducted by Jacobs et al.6, it showed that there
by work fatigue1.Work exhaustion has been estimated to is a significant relationship between work stress and
be a key factor as much as 41% of causes in various work fatigue, where respondents who experienced work
incidents of injuries, accidents and deaths2. stress have a 5 times greater chance of getting work
fatigue. Research by Tasmi et al.7 obtained a relationship
According to research conducted by Ricci et al.3 in
between energy intake and work fatigue. Based on these
America, there were 38% of workers experiencing
studies, the category of mild fatigue was found in the
fatigue related problems in work capacity. Fatigue appropriate energy intake of 7 workers (11.5%) and in
problems arise due to low energy levels and energy intake as inappropriate categories as many as 11
insufficient sleep. people (18.0%). Meanwhile, work fatigue in the tired
10% of workers reported unproductive time to reduce category was found in the energy intake of the non-tired
performance and disrupt their concentration. The results category as many as 31 people (50.8%). Meanwhile,
of study conducted by O’Neill et al.4 on Queensland heavy work fatigue category was found in inappropriate
construction projects showed that when fatigue increased energy intake as many as 12 people (19.7%). In a study
among workers, productivity decreased. This is conducted by Pasira8, there was a relationship between
confirmed through correlation analysis, which disclosed years of work and work fatigue among tofu factory
that fatigue has a relationship with the level of workers. The results of the study showed that all 18
productivity. It was also found through productivity workers with long working years experienced fatigue.
analysis that the average cost due to fatigue caused a Workers with a short working period also
decrease in the production rate of $ 50,000 per year. experienced
1067 Indian Journal of Public Health
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Journal &
of Development,
Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1067

fatigue as many as 12 workers (75.0%). Another factor the number of respondents with low work stress is
associated with work fatigue is haemoglobin, Hb level. 18
Lack of Hb can cause a lack of oxygen (O2 ) channelled people or 45% and high stress is 22 people or 55%.
to cells of the body and brain, eventually causing
symptoms of fatigue, lethargy and fatigue which results Energy intake is grouped into two categories,
which are insufficient if<the total energy needed and
in employees being able to reduce work productivity9.
sufficient if ≥the total energy needed. Table 1 revealed
Based on the description above, the authors are that from the 40 number of respondents, the number
interested in conducting research on factors related to of respondents with not fulfilling energy intake was as
work fatigue in workers in the block paving production many as 23 people and the number of respondents with
unit of CV SumberGalianBiringkanayasub-district, energy intake that is sufficient was as many as 17 people.
Makassar for the year 2017.
The working period is grouped into short which
is
Methodology working period is <3 years and long if the years
are ≥
The type of research used, was observational 3 years. Table 1 showed that from the 40 respondents,
analytic research with a cross sectional study it can be seen that the percentage of respondents with a
approach. The aim was to observe the relationship of short term of work as many as 47.5% and the number of
the independent variables to the dependent variable, respondents with long working period was 52.5%.
namely work period, work stress, energy intake and
haemoglobin level among workers in the block paving The work fatigue measured in this study is physical
production unit of CV. SumberGalian Makassar. fatigue experienced by respondents using the reaction
This research was conducted in February 2017 at timer tool. Fatigue of work in this study is divided into
CV. SumberGalianJalanPerintisKemerdekaan km 18, 2 categories, namely experiencing fatigue if the reaction
Biringkanaya District, Makassar City. time is> 240 milliseconds and not experiencing fatigue if
the reaction time is ≤ 240 milliseconds. The data in
The population in this study is all labour force in the Table
block paving block production unit of CV. 1revealed that from 40 respondents, it was known that
SumberGalian with as many as 40 people. The number respondents who experienced fatigue were 22 people
of samples to be examined is taken using the exhaustive or 55% whereas the remaining 45% did not experience
sampling method, which is based on a relatively small fatigue.
population of 40 people, and then the entire population
is sampled in this study (total sample). Data and
Table 1: Distribution of respondents according to
information are obtained by direct interviews using
job stress, energy intake, working period, and work
questionnaires distributed to respondents to find out
fatigue
data on work stress, energy intake, and work period.
Furthermore, work fatigue measurements were carried Frequency
out using a reaction timer for the 40 respondents. The Category Percentage
n
collected data were analysed for univariate analysis, (%)
bivariate analysis and multivariate analysis and the Job Low (≤ 90) 18 45.0
findings were tabulated in table form. stress High (> 90) 22 55.0
Energy Insufficient 23 57.5
Result and Discussion intake Sufficient 17 42.5
Univariate Analysis: Table 1 presented the distribution Working Short (< 3 years) 19 47.5
of respondents according to job stress, energy intake, period Long (≥ 3 years) 21 52.5
working period, haemoglobin level and work fatigue. Work Experienced fatigue 22 55.0
fatigue No fatigue experienced 18 45.0
Job stress is grouped into 2 categories, namely low
stress if total stress level ≤ 90 and high stress if the total The following in Table 2 is the measurement result
score is > 90. Table 1 showed that from 40 respondents, of subjective feelings of fatigue after work based on
the questionnaire. Based on the data in Table 2, it was
found that out of 40 respondents, the feeling of fatigue
1068 Indian Journal of Public Health
IndianResearch
Journal &
of Development,
Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1068
that is often experienced by the workers are
difficulty
in thinking with 55.0%, 16 people or 40% tired of Bivariate Analysis: Based on the research that has
talking, 9 people or 22.5% feeling nervous, 28 people been done, the data obtained regarding the relationship
or 70.0% having difficulty concentrating, 30 people of work stress with work fatigue is presented in
or Table
75% having difficulty in focusing attention, 31 people or 3. Table 3 showed that the percentage of respondents
77.5% often feeling forgetful, 23 people or 57.5% lack who experienced more fatigue were workers with high
of self-conscious, 21 people or 52.5% feeling anxious, work stress categories as many as 17 workers or 77.3%
compared to low work stress as many as 5 workers
21 people or 52.5% difficult to control attitude, 33
or
people or 82.5% feel lazy, 33 people or 82.5% feel
27.8%. Whereas in the percentage of respondents who
headaches,
did not experience fatigue with low occupational stress
37 people or 92.5% suffering from stiff shoulders, 40 categories as many as 13 workers or 72.2% compared to
people experienced back pain, 27 people or 67.5% feel high work stress as many as 5 workers or 22.7%. Data
suffocated, 40 people feel dehydrated, 28 people or 70% analysis using Chi-square test obtained a value of p
feel hoarse and 36 people or 90% tremble. =
0.002 which can be interpreted that there is a
Table 2: Distribution of respondents according to relationship between work stress and the occurrence of
work fatigue among block paving workers.
fatigue feeling
The following results of cross tabulation between
Frequency
energy intake and work fatigue showed that the
Fatigue feeling Percentage
n percentage of respondents who experienced fatigue
(%)
were workers with insufficient energy intake category
Thinking difficulties 22 55.0 as many as 17 workers or 73.9% compared to those
Tired of talking 16 40.0 with sufficient energy intake as many as 5 workers
Nervous 9 22.5 or
Concentrating difficulties 28 70.0 29.4%. While the percentage of respondents who did
not experience fatigue were workers with sufficient
Attention focusing difficulties 30 75.0
energy intake category as many as 12 workers or 70.6%
Often forget 31 77.5 compared to the lack of energy intake as many as 6
Lack of self-conscious 23 57.5 workers or 26.1%. Based on data analysis using the Chi-
Anxious 21 52.5 square test, the value of p = 0.005 proved that there is a
Attitude controlling difficulties 21 52.5 relationship between energy intake and the occurrence
of fatigue in block paving workers.
Laziness 33 82.5
Headaches 33 82.5 With reference to Table 3, the percentage of
Stiff shoulders 37 92.5 respondents who experienced fatigue with a long
Back pain 40 100.0 working period was 15 workers compared to 7 new
workers. Whereas the percentage of respondents who
Suffocated 27 67.5
did not experience fatigue among workers with a short
Dehydrated 40 100.0 service period was 12 workers compared to the long
Hoarse 28 70.0 working period of 6 workers. Based on data analysis
Tremble 36 90.0 using the Chi-square test, the value of p = 0.028 meant
that there is a relationship between years of work and the
occurrence of work fatigue.

Table 3: Relationship between job stress and fatigue

Fatigue categories Total

Category Experienced fatigue No fatigue experienced p value
n %
n % n %
High 17 77.3 5 22.7 22 55.0
Job stress 0.002
Low 5 27.8 13 72.2 18 45.0
Insufficient 17 73.9 6 26.1 23 57.5
Energy intake 0.005
Sufficient 5 29.4 12 70.6 17 42.5
Long 15 71.4 6 28.6 21 52.5
Working Short 7 36.8 12 63.2 19 47.5 0.028
period
Multivariate Analysis: The results of the Chi-square In this study due to insufficient energy intake status
analysis of the 4 independent variables were examined in block paving workers, there was an imbalance between
in this study consisted of job stress, energy intake, and the energy needed and the total energy intake which had
work period. From the four variables studied, the results an effect on the efficiency and productivity of these
showed that work stress variables, energy intake, and workers. Therefore, it was easier for these workers to
years of work were related to work fatigue among the experience fatigue. This is in line with Gavhed12, theory
workers. The results of logistic regression tests between whereby energy intake is needed by the workforce to
independent variables and dependent variables can be maintain the body’s condition to always be energetic.
seen in Table 4. Table 4 showed that the lowest p value Lack of energy intake results in health problems and
is in the job stress variable with p = 0.025 and Wald work productivity. The level of energy intake, especially
value for heavy workers is a determinant of the degree of work
= 5.040, Exp (B) = 0.102. Since the value of p<0.05, productivity. Heavy workers, if not balanced with
it can be concluded that the most influential variable sufficient energy intake, usually will speed up the fatigue
on work fatigue among block paving workers in CV. process.
SumberGalian for the year 2017 is job stress.
Furthermore, in this study the long working period
of respondents, had created the boredom feeling due to
Table 4: Regression of Fatigue among Block Paving
monotonous work. Hence, this affects the level of fatigue
Workers in CV. Galian Source for year 2017
experienced by many of the veterans block paving
Variable Wald p-value Exp (B) workers. This is justified by Sadeghniiat-Haghighi
Job stress 5.040 0.025 0.102 et al.13 study that the long working period carried out
Working period 4.502 0.034 0.070 monotonously and continuously can lead to feelings of
Energy intake 3.527 0.060 9.895 fatigue and ones’ work experience will affect the level of
work fatigue. Syavina et al.14 stated that the duration of
Constant 3.266 0.071 20.374
work is one of the factors included in the component of
occupational health science. Physical work carried out
Discussion continuously for a long period will affect the mechanism
In this study, there are differences from the results in the body (circulatory, digestive, muscle, nerve, and
of measurements using questionnaires and reaction respiratory systems). In this situation, fatigue occurred
timer measuring instruments. Based on the results of due to the accumulation of residual products in the
the questionnaire from 40 respondents, they stated muscles and blood circulation where the remaining
that they experienced signs of fatigue whereas based products are limiting the continuity of muscle activity.
on the reaction timer results, it was found that only 22
workers experienced physical fatigue. This is due to the Conclusion
measurement using the questionnaire is only subjective
about what is felt by the workers while the measurement Based on the results of research and analysis of
using the reaction timer is more of a measurement of the variables studied about factors related to work
physical fatigue with an approach to test the accuracy fatigue in paving block workers in CV. SumberGalian,
and speed of completing work. Biringkanaya District, Makassar City In 2017, the
conclusions can be drawn are as follow:
The respondents who experienced fatigue were
more compared to those who were not tired due to job 1. There is a relationship between job stress,
stress factors, energy intake, and working period. The energy intake and working period with work
job stress experienced by block paving workers in this fatigue in block paving workers in CV. Source
study was higher stress compared to those who with of GalingBiringkanaya District, Makassar City,
mild/low stress. Thus, these workers experienced fatigue 2017.
faster. This is in line with the theory of Mehta10 which
stated that in reality stress is present in every individual 2. The most influential factor on work fatigue in
and is part of life. There is no life free from stress. block paving workers in CV. SumberGalian,
According to the DepKes ,one of the clinical
11 Biringkanaya District, Makassar City, 2017 is job
manifestations of job stress is work fatigue. stress factor.
Acknowledgement 6. Jacobs BW, Kawatu P, Maramis F. Relationship
between Work Structures and Exhaustions at
The authors would also like to express their
Employees in Resources Source Human at PT.
gratitude towards all the respondents at CV. Sumber
Sulut Bank Manado Branch. Journal of Public
Galianwho was willing to participate in this study.
Administration. 2015 Nov 4;4(32).
Ethical Clearance: Taken from the committee 7. Tasmi D, Lubis HS, Mahyuni EL. Hubungan
Status Nutrition and Energy Intake with Work
Source of Funding: Nil
Fatigue for Workers at PT. Perkebunan Nusantara
Conflict of Interest: Nil II Three Years Palm Oil Mill 2015. Journal
of Environmental and Occupational Health.
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15;14(24):3464-71. 9. Untari R, Hersusanto HB. Anemia and fatigue in
2. Hofmann DA, Burke MJ, Zohar D. 100 years women who work at night. Gateway of Innovation.
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of workplace safety and risk. Journal of applied on neuromuscular fatigue development and
psychology. 2017 Mar;102(3):375. associated heart rate variability. International
3. Ricci JA, Chee E, Lorandeau AL, Berger J. Journal of Obesity. 2015 Feb;39(2):208.
Fatigue in the US workforce: prevalence and 11. Indonesian Ministry of Health. Ministry of Health
implications for lost productive work time. Strategic Plan 2005-2009. Jakarta: Indonesian
Journal of Occupational and Environmental Ministry of Health. 2006.
Medicine.
12. Gavhed D. Work in Heat and Cold. In
2007 Jan 1;49(1):1-0.
Occupational Physiology 2016 Apr 19 (pp. 248-
4. O’Neill C, Panuwatwanich K. The impact of 281). CRC Press.
fatigue on labour productivity: case study of dam
13. Sadeghniiat-Haghighi K, Yazdi Z. Fatigue
construction project in Queensland. Proceedings
management in the workplace. Industrial
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psychiatry journal. 2015 Jan;24(1):12.
5. Putra H, Sinaga MM, Mahyuni EL, Kesehatan
14. Syavina M, Yuantari M, Nurjanah C. Factors
MP, USU KK, Kesehatan DD. Relationship
Associated With Exhaustion at the Cleaning
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Concrete Reinforcement Production Workers in
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Safety FKM USU. 2015.
DOI Number: 10.5958/0976-5506.2019.01723.6

Factors toward Diabetes Mellitus Type II Occurrence among

Patients in Tenriawaru Hospital, Bone Regency 2014

Jumriani Ansar1, Indra Dwinata1, Hardiana1

1
Faculty of Public Health, Hasanuddin University, Makassar, Indonesia

ABSTRACT
Diabetes mellitus among patients in Tenriawaru Hospital tend to increase from year 2009 until 2012.
In 2009, patient numbers were 104 patients and increased to 166 patients in 2012. This study aimed to
determine the risk of age, obesity, gender and hypertension on the diabetes mellitus (DM) type II among
patients in Tenriawaru Hospital, Bone regency. The study had been used simple random sampling with
cross sectional design. The study population were all patients had undergone treatment in inpatients ward at
Tenriawaru Hospital, Bone regency. The sample sizes were 192 patients who met the inclusion criteria. The
result showed that there was correlations between gender (p=0.000), age (p=0.001), hypertension (p=0.020)
and obesity (p=0.000) with DM type II occurrence in patients at Tenriawaru Hospital. The recommendation
that need early detection for DM diseases, prioritized non-pharmacological treatments such as diet changes,
exercise regularly and healthy lifestyle habit. Meanwhile, the hospital management should provide medical
nutrition consultation services for DM patients.

Keywords: Diabetes mellitus, age, obesity, hypertension, gender

Introduction smoking habit, alcohol consumption, lack of physical
activity, poor nutrition during pregnancy, ethnicity and
Diabetes mellitus (DM) is one health problem that
household income.6 Meanwhile, stroke risk is increased
tends to increase from year to year. DM also known
by 150% to 400% while risk of stroke related to
as diabetic or blood sugar disease. An estimated 171
dementia is increased by more than 3 fold for DM type
million people suffering diabetes globally in 2000 and
II patients.6
increased to more than 366 million in 2011.1 In 2017,
approximately 425 million people aged between 20 In 2007, Basic Health Research (Riskesdas) showed
years and 70 years were suffered DM and expected that DM prevalence was 5.7% while DM risk factors
increased to 629 million by 2045.2 included disturbed glucose tolerance prevalence of
10.2%. The DM prevalence increased due to obesity,
Diabetes mellitus (DM) is characterized by chronic
hyperglycaemia, hyper cholesterol, lack of physical
hyperglycaemia and impaired carbohydrates, lipids
activity, lack of fibre consumption, smoking habit and
and proteins metabolism due to partial or complete
genetic factors.
insufficiency of insulin secretion and/or insulin action.2,3
DM type I was caused by absolute deficiency in In Indonesia, one province had experienced
insulin due to secretion failure by the pancreas, while increment in DM type II cases was South Sulawesi
DM type II is characterized by insulin resistance and province. Based on Health Service of South Sulawesi
relative insulin deficiency, either or both of which may province, non-communicable diseases found DM
be present at time diabetes is diagnosed.4 DM type II (6.65%) in 2008. In 2009, DM was found 4.99% and
is most common of DM which involved between 90% increased to 14.24% with highest number of mortality
and 95% of all diabetic patients3. Besides, DM type II was equal to 41.56%. Meanwhile, DM cases were
is caused by cardiovascular disease (CVD), blindness, 29.38% with mortality of 13.4% in 2011 and DM
renal failure and amputations with tremendous impact increased to 27.64% in 2012.
on health expenditure.5 Furthermore, DM type II also
caused by advanced age, obesity, family history of DM, In Tenriawaru Hospital, DM was found increased
from year 2009 to 2013. In 2009, DM patients
were
1072 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

104 patients and increased to 166 patients by 2012. Table 2: Respondent distributions based on
Based on DM prevalence trends in various regions, hypertension in Tenriawaru Hospital, Bone regency
thus understanding of future DM with its complications 2014
which caused morbidity and mortality in Indonesia. This
study aimed to determine the risk of age, obesity, gender Frequency Percentage
Hypertension status
(n) (%)
and hypertension on the diabetes mellitus (DM) type II
among patients in Tenriawaru Hospital, Bone regency. Hypertension 135 70.3
Non-hypertension 57 29.7
Methodology Total 192 100.0

In Table 3, there were 94 female respondents

The study was used observational with cross section (69.1%) suffered DM type II and 42 female respondents
approach which observed the relationship between risk were non- DM type II patients. In additions, 18 male
factors for disease occurrence or certain health status at respondents (32.1%) were suffered DM type II and 38
same times. The study was conducted at medical record male respondents (67.9%) were non-DM type II. The
room of Tenriawaru, Bone Regency which reference result showed there was relationship between gender
and DM type II occurrence in Tenriawaru Hospital.
from public health centres (Puskesmas) or doctors
visited by the community especially the Bone regency Table 3: Relationship between gender and DM type
residence. The study was conducted in February 2016. II in Tenriawaru Hospital, Bone regency 2014

The study population were all patients who had DM type II status
undergone treatment in Tenriawaru Hospital, Bone Gender Yes No Total p-value
regency. The sampling was selected using simple n % n % n %
random sampling who met the inclusion criteria. The Female 94 69.1 42 30.9 136 100.0
0.000
sample sizes were 192 patients. The data was collected Male 18 32.1 38 67.9 56 100.0
through secondary data. The secondary data was
In Table 4, 93 respondents (65.5%) were aged
obtained by collected and recorded from medical record below than 45 years old and 19 respondents (38%) were
or DM type II patients status books. The data was aged more than 45 years old with DM type II.
analysed with SPSS computer program. The data was Meanwhile, 49 respondents (34.5%) were aged more
represented in table form and narration. than 45 years old and 31 respondents who aged more
than 45 years old did not suffered DM type II. The
statistical test showed there was relationship between
Result and Discussion
gender and DM type II occurrence in Tenriawaru
Hospital.
In Table 1, 106 respondents were categorized as
non-obese and 86 respondents (44.8%) were categorized Table 4: Relationship between age and DM type II
as obesity. in Tenriawaru Hospital, Bone regency 2014
DM type II status
Age
Yes No Total p-value
Table 1: Respondent distribution based on body (years)
n % n % n %
mass index (BMI) criteria in Tenriawaru Hospital,
≤45 93 65.5 49 34.5 142 100.0
Bone regency 2014 0.001
>45 19 38.0 31 62.0 50 100.0
BMI criteria Frequency (n) Percentage (%) Meanwhile, 50 respondents were obesity and 62
Non obesity 106 55.2 respondents (55.5%) were categorized as non-obesity
with suffered DM type II as shown in Table 5. Besides,
Obesity 86 44.8
56 respondents (55.2%) were obesity and 24 respondents
Total 192 100.0 (44.9%) were non-obesity which did not suffered DM
In Table 2, there were 135 respondents (70.3%) type II. The statistical test showed there was relationship
suffered hypertension and 57 respondents (29.7%) were between BMI status and DM type II occurrence in
non-hypertension patients. Tenriawaru Hospital.
Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 1073
Table 5: Relationship between BMI status and DM In Table 6, 86 respondents (63.7%) were
type II occurrence in Tenriawaru Hospital, Bone hypertension and 26 respondents (45.6%) were non-
regency 2014 hypertension with suffered DM type II. Meanwhile, 49
respondents (36.3%) were hypertension and 31
DM type II status
BMI respondents (54.4%) were non-hypertension with non-
Yes No Total p-value
status DM type II. The result also showed that a relationship
n % n % n % between hypertension and DM type II in Tenriawaru
Obesity 50 44.8 56 55.2 142 100.0 Hospital.
Non- 0.001
62 55.1 24 44.9 50 100.0
obesity

Table 6: Relationship between hypertension status and DM type II in Tenriawaru Hospital, Bone regency 2014
DM type II status
Hypertension
Yes No Total p-value
status
n % n % n %
Hypertension 86 63.7 49 36.3 135 100.0 0.001

Discussion In additions, the result indicated that gender also

one of factor correlated with DM type II occurrence in
In this study, the result found correlation between
Tenriawaru Hospital. The obesity among factor caused
age and DM type II occurrence in Tenriawaru Hospital.
DM type II in women. In global, the prevalence in male
The age is one of the factors associated with DM type II.
and female is very similar but men had higher incidence
DM was found increment cases in developing countries
than women based on obesity occurrence in DM type II
which most DM patients were aged between 45 years
risk factor.13 Meanwhile, a study found European male
and 64 years.7 In aging period, the cell production was
were usually diagnosed with diabetes at an earlier age
decline lead to changes in beta cell morphology.
with lower BMI than women.14
Besides, DM in older adults dude to decrease in tissue
function as changes in tissue itself. In this study, the result found correlation between
hypertension and DM type II occurrence in Tenriawaru
Obesity is defined as abnormal or excessive fat
Hospital. There were 63.7% respondents were suffered
accumulation that affect health with BMI≥30 kg/m2.8,9
DM while 36.3% respondents found did not suffered
The result also indicated that obesity was one of factor
DM. Hypertension was two to three times more frequent
correlated with DM type II in Tenriawaru Hospital. This
in diabetic patients.15 The pre-hypertensive state is
study found that there were 86 patients (44.8%) with low
categorized once systolic blood pressure between 120
risk while there were 106 patients (55.2%) with high
and 138 mmHg and/or diastolic blood pressure between
risk. Obesity also related with excess body fat which
80 and 89 mmHg.16 Hypertension and DM type II were
greatly increased risk for insulin resistance.10 The insulin
two conditions that closely related. Around 30%-60% of
resistance contributed to increase glucose production
DM patients had history of hypertension.
in the liver and decrease glucose uptake in muscle and
adipose tissue at set insulin level.11 In Turkey, obesity
was correlated with age (highest prevalence in adult Conclusion
aged between 50 years and 69 years old), female gender, In conclusion, the study found relationship between
hypertension, hyperlipidaemia, diabetes, parity, smoking age, gender, obesity and hypertension with DM type
habit, alcohol consumption, marital status (married and II in Tenriawaru Hospital. The recommendation are
widowed), occupation (housewife, tradesman, officers high risk group should maintain healthy lifestyle and
and retied), household income, family history of obesity, food consumption. Besides, the women is suggested
diabetes and hypertension and lack of physical activity to maintain their body weight and perform exercise to
in Turkish adults.12 prevent the obesity which can contributes to DM.
1074 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Acknowledgement 7. Olokoba AB, Obateru OA, Olokoba, LB. Type

2 diabetes mellitus: a review of current trends.
The author would like to thank to Tenriawaru
Oman Medical Journal. 2012; 27(4): 269-273.
Hospital for information support.
8. Ellulu M, Abed Y, Ranneh Y, Ali F.
Ethical Clearance: Taken from the committee Epidemiology of obesity in developing countries:
challenges and prevention. Global Epidemic
Source of Funding: Nil
Obesity. 2014; 2(2). doi:
Conflict of Interest: Nil htpp://dx.doi.org/10.7243/2052-5966-2-2
9. Agofure, O. Prevalence of obesity among adults
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DOI Number: 10.5958/0976-5506.2019.01724.8

Mapping of Dengue Fever Incidence in Majjene Province,

West Sulawesi 2016

Jufri1, Agus Bintara Birawida1, Fajaruddin Natsir1

1
Faculty of Public Health, Hasanuddin University, Makassar, Indonesia

ABSTRACT
Majene province is an endemic area of dengue haemorrhagic fever. Several factors played a role in
changes of dengue haemorrhagic fever cases were rainfall, population density and vector density of dengue
haemorrhagic fever in term of larva-free numbers. This study aimed to describe the dengue haemorrhagic
fever patients distribution in Majene district, West Sulawesi province. The study had been used
observational with descriptive design. The study population was all positive dengue haemorrhagic fever
patients recorded in Maejn Health Office report in 2016. The study samples were 199 positive patients. The
data was analysed with SPSS program and ArcGis. The result indicated that spatial trend pattern in dengue
haemorrhagic fever cases tend to concentrate in one area such as coastal areas especially urban areas which
had high rainfall of
100-200 mm. In area with high rainfall also had very dense population that contributed transmission rapid
spread. Besides, larvae free number did not meet the requirement issued by Ministry of Health which was>
95%. The dengue haemorrhagic fever program should be prioritized in areas with high rainfall and dense
population. In additions, the larvae free program achievement will be further enhanced by increase budget
and improved as cross program.

Keywords: Dengue haemorrhagic fever, larvae free, dense population,

rainfall
Introduction sudden onset of fever, thrombocytopenia and vascular
leak syndrome and affected children under 15 years.8
Dengue virus infection is worldwide health
threat
affecting at least 3.6 billion people living in more
than
125 tropics or subtropics countries.1,2 An approximately
50-100 million dengue fever and 200,000-500,000
dengue haemorrhagic fever (DHF) caused 24,000
mortality annually.3,4

World Health Organization (WHO) declared dengue

and dengue haemorrhagic fever to be endemic in the
Asian sub-continents.3 Dengue virus is belonging to the
genus Flavivirus (group B arbovirus, RNA virus) and
includes structural and non-structural proteins.5 There
are four distinct serotypes such as DENV-1, DENV-2,
DENV-3 and DENV-4 which transmitted to human
through Aedes aegypti and Aedes albopictus
mosquitoes.6

Aedes (Stegomyia) aegypti is the main vector global

and found in urban environment and Aedes (Stegomyia)
albopictus was considered secondary importance in
transmission expect in Asian countries which present in
rural or semi-urban habitats.7 DHF is characterized by
DHF can be correlated with poor outcomes
depending
on the facilities availabilities for patient management.2

DHF is one important public health problem in

Indonesia. The mosquitoes transmission (vectors) of
DHF are Aedes aegypti, Aedes albopictus and Aedes
scutellaris. The existence of vectors (larvae of Aedes
aegypti) in the area indicated presence of Aedes aegypti
mosquitoes population in that area.

DHF vector density level can be observe through

larvae surveillance. The larvae surveillance was carried
out with calculation were obtained to find out the larvae
index included larvae free number, house index,
container index and breteau index. All regions in
Indonesia are in risk of contracting dengue diseases.
DHF is influenced by environmental conditions,
population mobility, population density, presence of
artificial and natural containers in landfills (TPA) and
other garbage places.

High population density increases dengue infection

since flying distance of mosquitoes is estimated at
50 meters. Besides, temperature and humidity are
also among environmental conditions that affects
development of Aedes aegypti.
1076 Indian Journal of Public Health
IndianResearch
Journal &
of Development,
Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1076

In Majene district, dengue haemorrhagic fever respondents (46.2%) were aged between 0 year and 10
incidence found increased annually. In 2015, there years old. Besides, there were 40 respondents (33.6%)
were 16 DHF patients who treated and increased to aged between 11 years and 20 years old. There was only
199 DHF cases and four mortality cases were recorded. a respondent aged between 51 years and 60 years old. In
Meanwhile, Majene regency had DHF cases and additions, 67 respondents (56.3%) were students and 32
outbreaks due to surge in cases and mortality. This study respondents (26.7%) were unemployment.
had represented in map form. Map can illustrate dengue
haemorrhagic fever distribution that occurred in 2016
Table 1: Patient Distributions with dengue
based on environmental factors such as climate change,
haemorrhagic fever based on characteristics in
population density and larvae free percentage. This study
Majene district 2016
aimed to describe the dengue haemorrhagic fever
patients distribution in Majene district, West Sulawesi Characteristics Total (n) Percentage (%)
province. Gender
Male 65 54.6
Methodology Female 64 45.6
Age group (years old)
The study was used observational study with
descriptive research design to determine dengue 0-10 55 46.2
haemorrhagic fever distribution by observe with 11-20 40 33.6
population density and climate change and larval density 21-30 10 8.4
based on Geographic Information Systems (GIS). The 31-40 6 5
study location was conducted in Majene district, West 41-50 2 1.7
Sulawesi province between February and April 2017.
51-60 1 0.8
This district was selected due to this region was endemic
to dengue haemorrhagic fever and included in outbreak >60 5 4.2
area in 2016. Employment
Unemployment 32 26.9
The population were 119 dengue haemorrhagic
Student 67 56.3
fever positive patients recorded in Majen health Office
report. The samples were 199 positive patients in 2016. Civil servant/
6 5
lecturers
The primary data was obtained by conducted direct
case survey, observed patient coordinates used GPS. Housewives 6 5
The patients who moved to domicile was still taken Entrepreneur 3 2.5
coordinates at residence place on positive dengue Farmers/Fisherman 5 4.2
haemorrhagic fever detection. Total 119 100
The secondary data were obtained from dengue Based in Table 2, there were seven respondents with
haemorrhagic fever data from relevant agencies mobility history from endemic areas from Makassar
such as Majene District Health Office. Meanwhile,
city. Meanwhile, seven respondents came from Malunda
climate variation in form of monthly report at Majene
subdistrict. Meanwhile, 5 respondents were from
Meteorology Station in 2016. The population density
Mamuju regency.
data was obtained from Majene Central Statistical
Agency. The larvae free numbers per Public Health
Centre (Puskesmas) was obtained from related office. Table 2: Patient distribution with dengue
The data was analysed with SPSS and GIS Arc haemorrhagic fever based on mobility history in
computer programs. The data was represented in form Majene district 2016
of maps, tables, graphs and narrative.

Result and Discussion Mobility history Total (n) Percentage (%)

Endemic area 16 13.4
In Table 1, 65 respondents (54.6%) were male
and Not traveling 103 86.6
64 respondents (45.6%) were female. Meanwhile, 55 Total 119 100
Table 3 showed average rainfall occurred in Majene km2. There were 4 subdistrict had very dense population
district in 2016. There were 4 sub district with extreme included Banggae and East Banggae. Meanwhile,
categories and another 4 sub district with high rainfall Pamboang and Sendana had dense population.
categories. Highest rainfall occurred in Ulumanda Ulumanda subdistrict had normal population density.
subdistrict with 240 mm and Tammeroddo had recorded
rainfall with 208 mm (extreme) and lowest rainfall was
Table 4: Population density population by category
in East Banggae with 142 mm (high).
in Majene district 2016

Table 3: Rainfall distribution in Majene district 2016 Sub district Population/km2 Category
Banggae 1579 Very dense
Sub district Rainfall Category East Banggae 1010 Very dense
Banggae 168 High Pamboang 311 Dense
East Banggae 142 High Sendana 269 Dense
Pamboang 162 High Tammeroddo 202 Less dense
Sendana 160 High Tubo Sendana 212 Less dense
Tammeroddo 208 Extreme Malunda 97 Less dense
Tubo Sendana 207 Extreme Ulumanda 19 Normal
Malunda 205 Extreme In Table 5, the larvae free numbers achievement in
Ulumanda 240 Extreme each subdistrict in Majene did not reached Ministry of
Table 4 showed Banggae subdistrict had highest Health target set which was >95%. Highest achievement
population density of 1579 population/km2 while in Pamboang subdistrict was 92.2% and lowest was in
Ulumanda district which had population of 19 Banggae subdistrict, 78.8%.
population/
Table 5: Larvae free number distribution achievement in Manene district 2016
Subdistrict Total house Checked house Larvae free Percentage
Banggae 7787 3757 2962 78.8
East Banggae 6555 3170 2742 86.5
Pamboang 4208 2730 2516 92.2
Sendana 4419 1665 1456 87.4
Tammeroddo 2371 560 514 91.8
Tubo Sendana 1721 730 658 90.1
Malunda 3775 1195 1077 90.1
Ulumanda 1688 720 657 91.3
Discussion In Majene district, the coastal areas were most
resided areas and connected with South Sulawesi, West
In this study, the maps showed distribution pattern Sulawesi and Central Sulawesi province which meant
of dengue haemorrhagic fever patients more likely to be community in Majene district were living in lowland
close together due to ability flying vector ability caused that were very potential as breeding place for dengue.
of dengue haemorrhagic fever which was only between
Meanwhile, positive dengue haemorrhagic fever
50m and 100m. patients in Majene district were widely spread in
urban areas which very closely related to environment
In additions, the dengue haemorrhagic fever also
sanitation such as waste management. In urban areas,
strongly influenced by height of the area since the result waste production was more than rural areas which
obtained in Majene district was mostly in the coastal contributed in Aedes mosquitoes breeding area if did not
areas along Majene district. treated well.
The dengue haemorrhagic fever incidence was The spot check activities were not carried out in all
widespread in areas with high rainfall (100-200mm) houses or building in their respective areas due to lack
than areas had extreme rainfall (>200mm). High rainfallof energy and costs allocated. Tubo Sendana subdistrict
category was found in Southern part of Majene district had 90.1% larvae free achievement but did not received
while extreme rainfall category was found in Northern by positive dengue haemorrhagic fever patients. The
part of Majene district. larvae free numbers was measure of larvae density
in an area to reduce the dengue fever risk or dengue
High dengue haemorrhagic fever incidence in
haemorrhagic fever transmission which necessary to
high rainfall areas compared to extreme rainfall areas
eradicate mosquito nests.
due to inundation created breeding ground for Aedes
mosquitoes while extreme rainfall caused flood lead
water flows full with Aedes mosquitoes larvae. The Conclusion
rain affected the mosquitoes life in two ways such as
In conclusion, positive dengue haemorrhagic
increased relative humidity and breeding ground. fever
Baggae subdistrict which had highest number of patients found more in areas with high rainfall (100-
positive dengue haemorrhagic fever patients in Majene 200mm) compared to areas with extreme rainfall. High
district which was 76.9% in adjacent to the shoreline. rainfall was caused inundation as breeding ground for
In general, distribution of dengue haemorrhagic fever Aedes mosquitoes. Meanwhile, areas with very dense
patients in all sub district was more prevalent in adjacent population had more dengue haemorrhagic fever
areas to the coast. patients. The population density also affected dengue
transmission since flying vector of disease was estimated
Population density was resident number living per to be only 50-100 meter. All subdistrict in Majene
unit area (km2). Denser the area, greater potential for district had <95% larvae free number or did not fulfil the
disease transmission. The population density affected requirement of Ministry Health.
the vulnerability of an area to several diseases especially
those that were closely related to the environment. The Acknowledgement
disease was more easily transmitted to the areas that
were densely populated due to transmission range was The author would like to thank to Majene District
getting closer. In additions, density and population were Health Office and related agencies for resources and
among the factors that influenced dengue incidence in information support.
the region.
Ethical Clearance: Taken from the committee
The region had very dense population such as in
urban areas had public facilities included health facilities Source of Funding: Nil
(hospitals, public health centres and general
Conflict of Interest: Nil
practitioners), other public facilities such as markets,
schools, tourist attraction, hotels that caused dengue
haemorrhagic fever was very easily transmitted the REFERENCES
diseases. 1. Sam SS, Omar SFA, Teoh BT, Jamil JA,
AbuBakar S. Review of dengue hemorrhagic
Besides, population mobility was also risk factors
fever fatal cases seen among adults: a
caused dengue haemorrhagic fever spread in Majene
retrospective study. PLoS Neglected Tropical
district. Most positive dengue haemorrhagic fever
Diseases. 2013; 7(5).
patients came from endemic areas such as Makassar city
and Mamuju regency. 2. Khurram M, Qayyum W, Hassan SJ, Mumtaz
S, Bushra HT, UmarM. Dengue hemorrhagic
The larvae free number achievement in seven fever: comparison of patients with primary and
district was <95% that did not meet the Ministry of secondary infections. Journal of Infection and
Health requirement. The presence of Aedes larvae Public Health. 2014; 7(2014): 489-495.
mosquitoes in the region indicated that there was
potential for dengue haemorrhagic fever to occur. 3. Itrat A, Khan A, Javaid S, Kamal M, Khan H,
Javed S, Kalia S, Khan AH, Sethi MI, Jehan,
I.
Knowledge, awareness and practices regarding 6. Raza FA, Rehman S, Khalid R, Ahmad J, Ashraf
dengue fever among the adult population of S, Iqbal M, Hasnain S. Demographic and clinico-
dengue hit cosmopolitan. PLoS ONE. 2008; 3(7):1- epidemiological features of dengue fever in
6. Faisalabad, Pakistan. PLoS ONE. 2013; 9(3).
4. Khan E, Kisat M, Khan N, Nasir A, Ayub S, 7. Melo DPO, Scherrer LR, Eiras ÁE.Dengue fever
Hasan, R. Demographic and clinical features of occurrence and vector detection by larval survey,
dengue fever in Pakistan from 2003-2007: a Ovitrap and MosquiTRAP: a space-time clusters
retrospective cross-sectional study. PLoS ONE. analysis. PLoS ONE. 2012; 7(7).
2010; 5(9):1-7.
8. Senyaolu A, OkorieC, Badaru O, Adetona K,
5. Fujimoto DE, Koifman S.Clinical and laboratory Ahmed M, et al. Global epidemiology of dengue
characteristics of patients with dengue hemorrhagic fever: an update. Journal of Human
hemorrhagic fever manifestations and their Virology and Retrovirology. 2017; 5(6).
transfusion profile. Brazilian Journal of
Hematology and Hemotherapy. 2014 36(2): 115-
120.
DOI Number: 10.5958/0976-5506.2019.01725.X

Factors Contribute to KB Contraception Equipment Service in

Reproductive Age Couples in Tamalanrea Public Health Center

Karmiah1, Muhammad Yusran Amir1, Muh. Yusri Abadi1

1
Faculty of Public Health, Hasanuddin University, Makassar, Indonesia

ABSTRACT
The contraceptive service is an effort to improve family planning quality. The study aimed to determine the
relationship between age, knowledge, education, employment, information provision and spouse support
in contraceptive services for reproductive age couples. The study was used quantitative research with cross
sectional study approach. This study was conducted at Tamalanrea Public Health Center (Puskesmas). The
study population were 3332 couples with samples of 97 reproductive age couples. The data collection was
done by distributed questionnaires to the samples. The data was processed with SPSS program and the data
was represented in frequency distribution table form. The result indicated there was correlation between
family planning contraceptive service in reproductive age couples with age (p=0.009), education level
(p=0.046), information provider (p=0.036) and spouse support (p=0.038). Meanwhile, there was no
relationship between family planning conceptive service with work (p=0.291) and knowledge (p=0.448). The
recommendation for health officers in provide information on contraceptive service usages for reproductive
age couples.

Keywords: Contraceptive, family planning, age, fertile, spouses

Introduction use no method at all. 6 In Egypt, 14% of pregnancies in
five years prior to the survey were reported unwanted
Family planning is defined as set activities,
and 5% of births were identified as mistimed.3 In 2010,
procedures and interventions that provide the population
American women unmet need was estimated at 5.9%
with counselling, health education and modern
and 23.2% in Africa.7The unmet need for contraceptive
contraceptive methods (CMs) for individuals may
contributes to 7.4 million disability-adjusted life years.8
choose their right to decide freely and responsibly
whether to have children and if so, the number and The contraceptive services is an effort to improve
appropriate timing of their children.1 Most developing family quality. Over past two decades, contraceptive
countries had higher unmet need for modern family services in family planning development in Indonesia
planning compared to developed countries. Meanwhile, is considered successful. Hence, there is increasing
most sub-Saharan countries had unmet need for family reproductive age women prevalence who used
planning between 13% and 34% in 2013.2 The unmet contraceptive methods. The family planning program is
need level is one of standard indication for measuring helps Indonesian through improving mothers, children
family planning effectiveness program in any country.3 and families development.
Family planning has potential to prevent most of The Indonesia health data showed family planning
maternal mortality and children and has economic and among reproductive age couples participation in
social benefits by providing correspondence between Indonesia had reached 76.73% in 2013 with injection
resources and population.4 and pills. In South Sulawesi province, highest
percentage of family planning methods used by active
There are around 210 million pregnancies happens family planning participants were injections (47.39%),
global which nearly 75-80 million of these pregnancies pills (22.90%), condoms (13.45%) and other methods
are unintended and more than half of these unintended (0.56%). Meanwhile, contraceptive method percentage
pregnancies undergo unsafe abortion annually. 5 95% of used for new family planning participant was injections
unintended pregnancies happened among women who (44.61%), pills (24.78%), condoms (16.85%), implants
either use their method inconsistently or incorrectly (8.84%), IUDs (3.21%) and others (0.28%).
or
1081 Indian Journal of Public Health
IndianResearch
Journal &
of Development,
Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1081

In Tamalanrea Public Health Centres (Puskesmas), Table 1: Relationship between age and family
contraceptive method had increased compared previous planning contraceptive in Tamalanrea Puskesmas,
year. The increment in family planning participants Makassar city
who selected injection method compared to other
Family planning concentrative
contraceptive methods was influenced by several factors service
Age
such as age, education level, employment status, number p-value
(years) Yes No Total
of children, age at first marriage, knowledge,
n % n % n %
information and contraceptive. The study aimed to
<20 5 62.5 3 37.5 8 100
determine the relationship between age, knowledge, 20-35 36 59.0 25 41.0 61 100
education, employment, information provision and >50 25 89.3 3 10.7 28 100 0.009
spouse support in contraceptive services for reproductive Total 66 68.0 31 32.0 97 100
age couples.
In Table 2, there were 41 respondents (71.9%)
Methodology had knowledge and 25 respondents (62.5%) had no
knowledge on contraceptive with utilized family
The study was used quantitative research with cross
planning contraceptive services in Tamalanrea
sectional study approach. The study was conducted in
Puskesmas. In additions, 16 respondents (28.1%) had
Tamalanrea Puskesmas, Makassar city from
knowledge and 15 respondents (37.5%) had no
December
knowledge on contraceptive without utilized family
2016 until January 2017.
planning contraceptive services. There was no
Meanwhile, the study population were married relationship between knowledge and family planning
couples in reproductive age in Tamalanrea Puskesmas contraceptive services utilization in Tamalanrea
which total of 3332 people. The sample sizes were 97 Puskesmas.
people which selected using non-random sampling
method.
Table 2: Relationship between knowledge and
The primary data was obtained through family planning contraceptive service utilization in
questionnaire and interview. The secondary data is Tamalanrea Puskesmas, Makassar city
obtained through documentation and other data. The Family planning concentrative

p-value
data was analysed used SPSS program. service
Knowledge
Yes No Total
The univariate analysis was performed on each
n % n % n %
variable used frequency analysis. The binary analysis
Yes 41 71.9 16 28.1 57 100.0 0.448
was performed used Chi square test to determine
No 25 62.5 15 37.5 40 100.0
the relationship between independent and dependent
Total 66 68.0 31 32.0 97 100
variables. The data was represented in form of frequency
distribution tables and percentages. In Table 3, there were 31 respondents (58.5%)
had high education level and 35 respondents (79.5%)
Result and Discussion had low education level with utilized family planning
In Table 1, 5 respondents (62.5%) were aged below contraceptive services in Tamalanrea Puskesmas,
than 20 years old and 25 respondents (89.3%) aged Makassar city. Besides, 22 respondents (41.5%) had
more than 50 years old had utilized family planning high education level and 9 respondents (20.5%) had
contraceptive. Meanwhile, 25 respondents (41.0%) aged low education level without utilized family planning
between 20 years old and 35 years old and 3 respondents contraceptive services. The statistical test showed there
(37.5%) aged below than 20 years old did not utilized was relationship between education level and family
family planning concentrative service. The statistical planning contraceptive services utilization in
test showed there was relationship between age and Tamalanrea Puskesmas, Makassar city.
family planning contraceptive service utilization.
Table 3: Relationship between education level and In Table 6, 35 respondents (59.3%) had spouse
family planning contraceptive service utilization in support and 31 respondents (81.6%) did not received
Tamalanrea Puskesmas, Makassar city spouse support with utilized family planning
Family planning contraceptive contraceptive services utilization. Besides, there

p-value
Education services utilization were 24 respondents (18.9%) had spouse support
level Yes No Total and
n % n % n % 7 respondents (18.4%) did not had spouse support
High 31 58.5 22 41.5 53 100.0 without utilized family planning contraceptive services

0.046
Low 35 79.5 9 20.5 44 100.0 utilization in Tamanlanrea Puskesmas, Makassar city.
Total 66 68.0 31 32.0 97 100

In Table 4, 41 respondents (73.2%) were worked Table 6: Relationship between spouse support and
and 25 respondents (61.0%) were jobless with utilized family planning contraceptive service utilization in
family planning contraceptive services. There Tamalanrea Puskesmas, Makassar city
were
Family planning contraceptive

p-value
15 respondents (26.8%) worked and 16 respondents
Spouse services utilization
(39.0%) were jobless without utilized family planning
contraceptive services. There was no relationship support Yes No Total
between employment and family planning contraceptive n % n % n %
services utilization. Yes 35 59.3 24 18.9 59 100.0

0.038
No 31 81.6 7 18.4 38 100.0
Table 4: Relationship between employment and Total 66 68.0 31 32.0 97 100
family planning contraceptive service utilization in
Tamalanrea Puskesmas, Makassar city Discussion
Family planning contraceptive
p-value

services utilization The pregnancy prevention is recommended for

Employment women with age less than 20 years. The contraceptive
Yes No Total
n % n % n % such as pills, IUDs, condoms which good in pregnancy
Yes 41 73.2 15 26.8 56 100.0 spacing. Meanwhile, women aged between 20 years and
0.291

No 25 61.0 16 39.0 41 100.0

35 years old is recommended to use contraceptive such
Total 66 68.0 31 32.0 97 100
as IUDs, pills, injections and implants. The women aged
Based on Table 5, 40 respondents (78.4%) had more than 35 years old is recommended to use IUDs,
received information and 26 respondents (56.5%) did implants, injections, pills and condoms. Hence, the age
not received information in contraceptive with utilized was determining the choices of contraceptive. The study
family planning contraceptive services. Furthermore, was indicated that there was relationship between age
11 respondents (21.6%) had received information and family planning contraceptive service utilization
and among reproductive age couples in Tamalnarea
20 respondents (43.5%) did not received information Puskesmas.
on contraceptive without utilized family planning
contraceptive services utilization in Tamalanrea The study also found there was no relationship
Puskesmas, Makassar city. between knowledge and family planning contraceptive
service utilization among reproductive age couples in
Tamalanrea Puskesmas. The reproductive age couples
Table 5: Relationship between information and
had sufficient knowledge in long term contraceptive
family planning contraceptive service utilization in
method selection through social media, electronics,
Tamalanrea Puskesmas, Makassar city
magazines. Meanwhile, 62.5% reproductive age
Family planning contraceptive couples had lack of knowledge and did not utilized
p-value

services utilization family planning contraceptive services. Besides, the

Information
Yes No Total
n % n % n % reproductive age couples who had sufficient knowledge
Yes 40 78.4 11 21.6 51 100.0 and did not utilized the family planning contraceptive
0.036

No 26 56.5 20 43.5 46 100.0 services caused by other factors which their spouse did
Total 66 68.0 31 32.0 97 100 not support in contraceptive usage.
The reproductive age couples who had insufficient result showed the respondents claimed their spouse dud
knowledge due to influences such as lack of information not oversee the contraceptive side effects. The spouse
about contraceptives and their side effects, lack support also influenced their wife in contraceptive
attendance in family planning counselling programs usage. The lack of spouse support toward contraceptive
but still obtained information from family and health side effect need improvement with paying attention to
officers. Furthermore, reproductive age couples who their wife health.
had lack of knowledge and did not utilized family
planning contraceptive services due to their ignorance Conclusion
in contraceptive usage. The women who inactive in
participating in counselling in local area which expected In conclusion, the study found there was correlation
able to consult with midwives about contraceptive between family planning contraceptive service in
method that suitable for their need. reproductive age couples with age, education level,
information and spouse support. Meanwhile, there was
The women education level also important in
no relationship between family planning conceptive
accessing to family planning information. Nowadays,
service with work and knowledge. The
the women had dual role as housewife and also role in
recommendation for health officers in provide
community activities. The study had indicated there was
information on contraceptive service usages for
relationship between education level and family
reproductive age couples.
planning contraceptive services utilization. The study
also showed reproductive age couples who ha low
education utilized family planning contraceptive services Acknowledgement
more which meant tendency of women with higher The author would like to thank to all respondents in
education will affect in contraceptive usage. Tamalanrea Puskesmas.
Besides, there was relationship between information Ethical Clearance: Taken from the committee
and family planning contraceptive services utilization.
The reproductive age couples who had received Source of Funding: Nil
information and did not utilized contraceptive services
caused by family advice on contraceptive method. Conflict of Interest: Nil
The information from health officers did not affected
the reproductive age couples decision in contraceptive REFERENCES
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5. Ramesh J, Chandrababu R. Community-based
family planning contraceptive services utilization.
This educational intervention on necklace method as
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DOI Number: 10.5958/0976-5506.2019.01726.1

Factors toward Dengue Haemorrhagic Fever Occurrence in

Patte’ne Village, North Wara District, Palopo City

Sari Puspa Bachtiar1, H.A. Arusnan Arsin1, Dian Sidik Arsyad1

1
Faculty of Public Health, Hasanuddin University, Makassar, Indonesia

ABSTRACT
Dengue Hemorrhagic Fever (DHF) is transmission disease through mosquitoes bites from genus Aedes
especially Aedes aegypti or Aedes albopictus. This study aimed to determine the relationship between
civil service efforts, hanging clothes habit, insect repellent usage, water reservoirs potential for mosquitoes
breeding and abate powder usage in Patte’ne village, North Wara district, Palopo city. The study was used
analytic observational with cross sectional study design. The study population were all household resided
in Patte’ne village which total of 745. The study samples were head of the family. The samples were used
proportional random sampling with samples of 254 households. The result showed that there was
relationship between hanging clothes habit, mosquitoes repellent usage, outside water reservoirs potential
for mosquitoes breeding, resting places inside the house existence and abate powder usage with DHF
occurrence in Patte’ne village, North Wara district. Meanwhile, there were no relationship between civil
service efforts, inside water reservoirs potential for mosquitoes breeding and resting places outside the
house with DHF occurrence in Patte’ne village, North Wara district. Health agencies is recommended to
provide counselling on 3M implementation to raise awareness in important of community participation in
dengue prevention.

Keywords: Dengue haemorrhagic fever, abate powder, civil service,

mosquitoes
Introduction enhancement (ADE).7 The dengue virus is maintained in
nature through cycle transmitted by Aedes mosquitoes
In 2010, International Research Consortium
between humans or monkeys for the jungle cycle.8
on Dengue Risk Assessment, Management and
Surveillance (IDAMS) estimated that 390 million In Indonesia, DHF endemic area was South
dengue infections global and 96 million are symptomatic Sulawesi province. Based on Prevention, Control and
cases.1 Meanwhile, World Health Organization (WHO) Environmental Health (P2PL), DHF incident rate
approximated 2.5 billion people were at risk of dengue was
which living in Africa, America, Eastern Mediterranean, 35.10% per 100, 000 population with highest incident
South East Asia and Western Pacific.2 rate was Palopo city had recorded 92.18% per 100,000
population. Palopo city is an endemic area of dengue
According to WHO, dengue fever (DF), dengue fever had 123 DHF outbreaks in February 2016.
hemorrhagic fever (DHF) and dengue shock syndrome
Therefore, the study was conducted on dengue
(DSS) which classified as with or without warning
occurrence in the city. However, this study only done in
signs and severe dengue.3 Dengue infection might cause
one Public Health Center working area such as Patte’ne
complications in nervous system and other clinical village, North Wara district. The study aimed to
complications with mortality consequences.4 Besides, determine the relationship between civil service
dengue also known as arboviral disease caused by the efforts, hanging clothes habit, insect repellent usage,
dengue virus and have four subtypes such as DEN-1, water reservoirs potential for mosquitoes breeding and
DEN-2, DEN-3 and DEN-4 with Aedes aegypti and abate powder usage in Patte’ne village, North Wara
Aedes albopictus as principal vectors.5,6 People who had district, Palopo city.
single primary infection have higher risk of developing
dengue hemorrhagic fever (DHF) and dengue shock Methodology
syndrome (DSS) which contributed to antibody-
dependent The study was used quantitative research which was
observational analytic with cross sectional study design.
1086 Indian Journal of Public Health
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Journal &
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Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1086

The study was conducted at North Wara district Public obtained from North Wara Puskesmas regarded the DHF
Health Centre working area in Patte’ne village in Palopo occurrence description in Patte’ne village in 2016.
city due to DHF outbreak area in 2016 within 21st
February until 9th March 2017.The study population The univariate analysis was represented frequency
were 745 household living in Patte’ ne village, North distribution and percentage of each study variable. The
Wara district, Palopo city. The study samples were head bivariate analysis was used to determine the relationship
of the family who willing became study respondents. and prove the hypothesis between independent and
The samples were 254 households. The samples were dependent variables. The analysis was used chi-square
selected with proportional random sampling. test analysis.

The study instrument was questionnaire sheet Result and Discussion

contained close questions related to study purpose. The In Table 1, there were 51 respondents (21.1%)
questionnaire consisted of 8 parts such as respondent claimed did not water reservoirs became mosquitoes
contribution, civil service efforts, hanging clothes habit, breeding place in their house with DHF occurrence in
mosquitoes repellent usage, water reservoirs potential Patte’ne village. Meanwhile, 191 respondents (78.9%)
did not had water reservoirs became mosquitoes
for mosquitoes breeding, resting places existence, abate
breeding place with no DHF occurrence in Patte’ne
powder usage and fogging.
village. There was no relationship between water
The primary data was obtained through reservoirs became mosquitoes breeding place and DHF
questionnaires. Meanwhile, secondary data was occurrence in Patte’ne village.

Table 1: Relationship between water reservoirs potential became mosquitoes breeding in the house and DHF
occurrence in Patte’ne village, North Wara district, Palopo city

Water reservoirs potential DHF occurrence

became mosquitoes breeding Yes No Total p-value
place n % n % n %
Yes 51 21.1 191 78.9 242 100
No 0 0.0 12 100.0 12 100 0.132
Total 51 20.1 203 79.9 254 100
In Table 2, 50 respondents (23.7%) had water reservoirs became potential for mosquitoes bleeding place and
only 1 respondents did not had water reservoirs which potential for mosquitoes bleeding place putside the house
with DHF occurrence in Patte’ne village, North Wara district, Palopo city. There was relationship between water
reservoirs potential became mosquitoes breeding place outside the house and DHF occurrence in Patte’ne village,
North Wara district, Palopo city.

Table 2: Relationship between water reservoirs potential became mosquitoes breeding outside the house and
DHF occurrence in Patte’ne village, North Wara district, Palopo city

Water reservoirs potential DHF occurrence

became mosquitoes Yes No Total p-value
breeding place n % n % n %
Yes 50 23.7 161 76.3 211 100
No 1 2.3 42 97.7 43 100 0.001
Total 51 20.1 203 79.9 254 100
In Table 3, there were 48 respondents (20.4%) had resting place for mosquitoes inside the house with DHF
occurrence and 3 respondents had no resting place for mosquitoes inside the house without DHF occurrence. There
was no relationship between resting place for mosquitoes inside the house and DHF occurrence in Patte’ne village,
North Wara district, Palopo city.
Table 3: Relationship between resting place for mosquitoes inside the house and DHF occurrence in
Patte’ne village, North Wara district, Palopo city

Resting place for DHF occurrence

mosquitoes inside Yes No Total p-value
the house n % n % n %
Yes 48 20.4 162 77.1 210 100
No 3 15.8 41 93.2 44 100 0.016
Total 51 20.1 203 79.9 254 100

In Table 4, 41 respondents (19.5%) had resting place for mosquitoes outside the house with DHF occurrence
in Patte’ne village, North Wara, Palopo city. Meanwhile, 169 respondents (80.5%) had resting place for mosquitoes
outside the house without DHF occurrence. The statistical test showed no relationship between resting place
mosquitoes outside the house and DHF occurrence in Patte’ ne village, North Wara district, Palopo city.

Table 4: Relationship between resting place for mosquitoes outside the house and DHF occurrence in
Patte’ne village, North Wara district, Palopo city

Resting place for DHF occurrence

mosquitoes outside Yes No Total p-value
the house n % n % n %
Yes 41 19.5 169 80.5 210 100
No 10 22.7 34 77.3 44 100 0.630
Total 51 20.1 203 79.9 254 100
In Table 5, 27 respondents (38.0%) did not used the environment is correlated with human behaviour.
abate powder and 24 respondents (13.1%) were used Environmental sanitation management that applied
abate powder with DHF occurrence in Patte’ne village, to suppress the Aedes aegypti larvae habitat through
North Wara district, Palopo city. There was no eradicated mosquito nests by 3M implementation.
relationship between abate powder usage and DHF
occurrence in Patte’ne village, North Wara district, The civil service efforts to implement 3M in
Palopo city. Patte’ne village, North Wara district, Palopo city were
fairly bad since 51 respondents had suffered dengue in
last three years. In this study, 153 respondents who
Table 5: Relationship between abate powder usage
claimed poor civil service efforts and found 36
and DHF occurrence in Patte’ne village, North
respondents (23.5%) suffered dengue in last three years.
Wara district, Palopo city
The statistical test showed no relationship between
DHF occurrence
p-value

Abate
civil service and DHF occurrence in Patte’ne village,
powder Yes No Total
usage North Wara district, Palopo city. Good civil service
n % n % n %
efforts in 3M implementation but the villagers still
No 27 38.0 44 62.0 210 100
0.000

affected by dengue due to other factors that influenced

Yes 24 13.1 159 77.3 44 100 the dengue occurrence such as environmental
Total 51 20.1 203 79.9 254 100 conditions.

The hanging clothes habit also medium favoured

Discussion
by mosquitoes transmission dengue and risk factors in
Eradication of mosquito nests was an activity dengue occurrence had increased. The community in
to eradicate eggs, larvae and pupa of Aedes awgypti Patte’ ne village had hanging clothes habit had hanged
mosquitoes that transmit dengue disease in their clothes outside cupboard such as behind the door.
breeding sites. The Aedes aegypti larvae existence Meanwhile, 51 respondents (20.1%) were affected
in by
dengue in last three years. There were 210 respondents The study also found relationship between abate
who had good habit and 48 respondents were suffered powder and DHF occurrence in Patte’ ne village, North
DHF. In this study, there was relationship between Wara district, Palopo city. In this study, there were 183
hanging clothes habit with DHF occurrence. The respondents who used abate powder and 24 respondents
community in Patte’ne village claimed hanged their (13.1%) who suffered from dengue. Based on the
clothes temporary at behind the door since the clothes interview, there were several reasons that did not used
were did not too dirty and smelly. Some respondents abate powder which were abate powder was sprinkled
into the water reservoir. Besides, some respondents
who practiced hanging clothes habit since received
who felt the powder was not important since no one had
information on dengue prevention.
suffered dengue. The health workers was provided abate
Healthy practices in DHF occurrence such as powder for every houses in Patte’ ne village since there
mosquitoes repellent usage. There were 189 respondents was an DHF outbreak in 2016.
used mosquitoes repellent and only 22 respondents Fogging was carried out if there are any dengue
(11.6%) were affected by dengue. Meanwhile, the cases from Health workers. The study found the
respondents who did not used mosquitoes repellent respondents claimed that fogging was carried out
were more affected by dengue which was 44.6% from throughout Patte’ne village area. The result showed
found suffered dengue in last three years. There was that 212 respondents who claimed fogging was
relationship between mosquitoes repellent usage with conducted around their houses and 49 respondents were
DHF occurrence in Patte’ne village. In additions, some suffered dengue. The fogging implementation in Patte’
respondents claimed never used mosquitoes repellent ne village was carried out due to existing of DHF cases
during day only used mosquitoes repellent at night. reported by Puskesmas officers. After fogging
implementation, DHF cases was observed reduced, thus
The water reservoir potential became breeding place there was relationship between fogging implementation
for Aedes aegypti mosquitoes in form of pupa such as and DHF occurrence in Patte’ ne village, North Wara
containers. Most respondents had habit did not closed district, Palopo city.
properly the water reservoirs such as bathtubs. There
were 152 respondents (59.8%) did not closed their Conclusion
water reservoirs which only done once per week. The
community in Patte’ne village who suffered dengue In conclusion, there was relationship between
which had water reservoirs that potential became hanging clothes habit, mosquitoes repellent usage,
outside water reservoirs potential for mosquitoes
breeding places inside the house. Besides, water
breeding, resting places inside the house existence and
reservoirs which did not closed properly also increased
abate powder usage with DHF occurrence in Patte’ne
potential in Aedes aegypti mosquitoes breeding. The
village, North Wara district. Meanwhile, there were
environment around respondents house also increased no relationship between civil service efforts, inside
potential became mosquitoes breeding place. water reservoirs potential for mosquitoes breeding and
resting places outside the house with DHF occurrence
Furthermore, Aedes aegypti mosquitoes resting
in Patte’ne village, North Wara district. Health
place inside the house were dark, moist and slightly
agencies is recommended to provide counselling on
clod places such as curtains, mosquito nets and clothes 3M implementation to raise awareness in important
hanging from inside house. The result showed 210 of
respondents had mosquitoes resting place in their community participation in dengue prevention.
houses. Besides, 51 respondents were suffered DHF
which 48 respondents had mosquitoes resting place in
Acknowledgement
their houses. Hence, most respondents were affected by
dengue found had mosquitoes resting place inside the The author would like to thank to all respondents
house. There was relationship between mosquitoes at Patte’ne village, North Wara district, Palopo city for
resting places in the house and DHF occurrence in unconditional support.
Patte’ne village, North Wara district, Palopo city. The
Ethical Clearance: Taken from the committee
hanging clothes habit in Patte’ne village in the house
also caused resting place for Aedes aegypti mosquitoes. Source of Funding: Nil

Conflict of Interest: Nil

REFERENCES 5. Zulkipli MS, Dahlui M, Jamil N, Peramalah D,
1. Swaminathan S, Khanna N. Dengue vaccine Wai C, Bulgiba A,Rampal, S. The association
development: global and Indian scenarios. between obesity and dengue severity among
International Journal of Infectious Diseases. 2019. pediatric patients: a systematic review and meta-
analysis. PLoS ONE. 2018; 12(2).
2. Cheah WK, Ng KS, Marzilawati AR, Lum LCS.A
review of dengue research in Malaysia. The 6. Atique S, Chan TC, Chen CC, Hsu CY, Iqtidar S,
Medical Journal of Malaysia. 2014; 69 (Suppl A): Louis VR, Shabbir SA, Chuan, TW. Investigating
59-67. spatio-temporal distribution and diffusion patterns
of the dengue outbreak in Swat, Pakistan. Journal
3. Rathakrishnan A, Klekamp B, Wang SM, of Infection and Public Health. 2018;
Komarasamy TV, Nathunam SK, Sathar J, 11(2018):
Azizan A, Sanchez-Anguiano A, Manikam R, 550-557.
Sekaran SD. Clinical and immunological markers
of dengue progression in a study cohort from a 7. Shim, E. 2017. Cost-effectiveness of dengue
hyperendemic area in Malaysia. PLoS vaccination in Yucatán, Mexico using a dynamic
ONE. dengue transmission model. PLoS ONE. 2017;
2014; 9(3). 12(4).

4. Ramadona AL, Lazuardi L, Hii YL, Holmner 8. Chen, W. J.Dengue outbreaks and the geographic
A, Kusnanto H,Rocklöv J. Prediction of dengue distribution of dengue vectors in Taiwan: a
outbreaks based on disease surveillance and 20-year epidemiological analysis. Biomedical
meteorological data. PLoS ONE. 2016;11(3). Journal. 2018; 41(2018): 283-289.
DOI Number: 10.5958/0976-5506.2019.01727.3

Factors that Influence Patients in Utilizing Outpatient Services

in Hasanuddin University Hospitals

Alamsyah1, Fridawathy Rivai1, Rini Anggraeni1

1
Hospital Management Department, Faculty of Community Health, Hasanuddin University

ABSTRACT
This study aims to analyze the factors that influence patients in utilizing outpatient services at Hospital of
Universitas Hasanuddin, which consists of hospital facility variables, physician services, nursing service or
midwife, service fee, ease of information, and service utilization decisions. This research type is
quantitative research with cross sectional design. Sampling technique with stratified random sampling.
The number of samples in this study is 100 respondents. Data collection using questionnaire instrument.
Data were analyzed by SPSS with Chi-Square statistic test. Chi-Square analysis showed that there were
correlation between hospital facility variable (p=0,004), physician service (p=0.033), nurse service or
midwife (p=0.011), ease of information (p=0.001) with service utilization decision. The advice given is to
maintain and provide the best service, should the hospital continue to make improvements on the
availability of facilities, type, or variety of health services more complete.

Keywords: Hospital; outpatient; services

Introduction capital intensive, so that hospital management becomes
a separate scientific discipline that produces two things
Consumer behavior is a process or activity when
at once, namely technology and human behavior in
someone searches, selects, purchases, uses, and
organizations6. Thus the hospital as a form of health
evaluates products and services to fulfill all aspects
service facilities engaged in the service sector actually
needed and desired1. Consumer behavior is an action
provides full attention to the quality of service, so that it
that is directly involved in acquiring, consuming, and
is used as an indicator of assessment by consumers or in
consuming products and services, including decisions to
this case patients.
overtake and follow these actions2.
Tjiptono et al.7 stated that the creation of customer
Parsons et al.3 stated that service is any action or satisfaction can provide several benefits including: 1)
activity that can be offered by a party to another party the relationship between the company and its customers
which is basically intangible and does not result in any become harmonious, 2) provide a basis for repurchasing
ownership. David et al.4 also defines service as a form of and creating loyalty, and the formation of word of mouth
product consisting of activities, benefits or satisfaction recommendations which can be profitable for the
offered for sale and basically intangible and does not company.
result in ownership of something. For example, banking,
hotels, airlines, taxes and home improvement services3,4. The potential of the hospital includes all the
resources owned including all hospital resources as
Purchasing health services is something that is often input, management as a process and health service
found by consumers. This type of purchasing service products as an outcome are expected to be able to sell
has special characteristics where most consumers feel the products produced. In order to remain competitive,
compelled to use it5.This ultimately affects the level of the products produced must be of quality and in
customer satisfaction and affects the willingness to use accordance with the criteria of community needs. In
the service again. determining target consumers, hospitals need to
understand consumer behavior in the decision-making
Hospitals are unique organizations, because they process8.
blend between solid technology, labor intensive and
The service process provided starts from the
registration stage until the patient receives treatment and
1091 Indian Journal of Public Health
IndianResearch
Journal &
of Development,
Public Health July 2019,&Vol.10,
Research No. 7 July 2019, Vol.10, No. 7
Development, 1091

healing. The form and procedure of services provided international standard education, research and health
by the hospital is tailored to the type of patient who care. So that with this vision hospitals are challenged in
is treated. Today, the types of patients who go to each facing the current era of competition with the number of
hospital are categorized as patients with health insurance hospitals in the city of Makassar.
or general patients9.
To achieve this vision Hasanuddin University
Health service utilization is the process of Hospital implements the mission of creating
interaction or relationship between consumers who use international-standard professionals in education,
services and health service providers. Where the research and health care; creating an optimal academic
interaction process is very complex and is influenced environment to support education, research and health
by many factors. These factors come from consumers, care; pioneering health care innovations through
the consumer environment, and providers in this case the superior research and continuous improvement in
Hospital9,10 service quality; provide integrated health care with
education, international standard research without
Basically, the community began to be smart in forgetting social functions; developing networks with
accessing health services, they began to demand good other institutions both regionally and internationally.
service in government institutions, where at the time
they only hoped for good service to private institutions 9- Therefore, this work aimed at identifying the factors
11
. Today government institutions are public institutions that influence patients in utilizing outpatient services at
that must provide good servants to the community as a Hasanuddin University Hospital. This is done in order
form of responsibility. Every leader of government to assess the characteristics of patients in the hospital,
agencies is always required to improve the quality of so they can determine the description of what kind of
service of the agencies they lead, especially agencies service a patient wants to be satisfied with the service
directly related to public services such as hospitals and and have the willingness to use

Common questions

Research identifies fast-food marketing, sedentary lifestyles, and changing family dynamics as key risk factors for childhood obesity. The study highlights that fast-food advertising targeting children and changes in lifestyle, such as increased screen time, contribute significantly to rising obesity rates .

Adaptive filters, such as those using floating-gate technology, enhance digital signal processing by allowing for programmable and adaptable filter circuits. This flexible approach enables the adjustment of filter parameters in real-time, improving signal clarity and reducing noise, which is crucial in non-invasive biomedical applications to monitor patient health without surgery .

Closed kinematic chain exercises were assessed using paired t tests to measure their impact on extremity recovery in subjects. Data analysis included pre and post-treatment measures of handheld dynamometer and goniometer, which demonstrated statistically significant improvements, with p values <0.0001, in both upper and lower limb strength and mobility .

The planned teaching program was highly effective, as indicated by the shift from 63.75% of mothers having average knowledge pre-test to 82.50% displaying good knowledge post-test. This demonstrates a significant increase in knowledge regarding pediatric emergencies, emphasizing the program's success .

The socio-economic status of slum dwellers significantly affects their nutritional and health conditions. Due to low socio-economic status, slum residents suffer from poor hygiene, inadequate sanitation, and insufficient nutrition, particularly among women and children, resulting in debilitating health conditions .

To counteract the effects of fast-food marketing, suggested interventions include implementing policies for nutritional labeling, taxing unhealthy food options, and promoting healthier alternatives like fruits and vegetables. Educating parents and regulating marketing practices can also mitigate adverse impacts on child nutrition .

Fast-food marketing significantly influences both children's and parents' eating behaviors by promoting fast-food consumption through targeted advertising. This marketing strategy often encourages the purchase of nutritionally poor food items, thereby contributing to obesity and related health issues .

The study utilized Repeated Measures ANOVA followed by Tukey Kramer multiple comparison tests to evaluate exercise interventions across different BMI groups. This approach assessed strength, endurance, flexibility, and quality of life improvements, showing a significant increase in post-exercise metrics with p values <0.0001 .

The therapeutic exercise program significantly improved pre-menopausal symptoms and quality of life as evidenced by the outcome measures used in the study, including the Menopausal Rating Scale (MRS) and SF-36 questionnaire. The pre and post-treatment analysis showed a statistically significant difference, with p values <0.0001, indicating the effectiveness of the program .

Post-intervention, there was a marked improvement in knowledge regarding permanent pacemaker care. Pre-test results showed 26% had poor knowledge, which improved significantly after the educational intervention, with 46% achieving a good knowledge level and none in the poor category .

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