Work Ability, Anxiety, and Depression among Long-Term Breast Cancer Survivors of Northern Kerala, India; A Historical Cohort Study.

BACKGROUND: Increasing number of breast cancer cases, and improved survival due to advancements in early detection, and treatment resulted in an increase in women living beyond a cancer diagnosis. Survivors have to face long-term physical effects as well as psychosocial issues post-treatment. This study aims to study survivourship in terms of work ability, anxiety and depression. METHODS: Retrospective cohort study on female breast cancer survivors from Hospital Based Cancer Registry (HBCR) of a Tertiary Cancer Centre (TCC). Data from 2016 (n=534) were collected from the medical records, and a follow-up survey (n=209) was conducted in 2022 to study their survivorship issues. RESULTS: In 2022, the mean age of the cohort (n=209) was 55.45 ± 9.36. The mean work ability score was 40.7±5.73 (95% CI 39.92 to 41.48).  In the multivariate binary logistic regression model, those who were married (OR 7.15, 95%CI 2.61 to 19.55), disease-free (OR 15.27, 95% CI 2.36 to 98.7), employed (OR 9.09, 95%CI 1.12 to 73.5), having no fatigue (OR 2.6, 95% CI 1.05 to 6.48), no pain (OR 3.11, 95% CI 1.16 to 8.35), and no depression (OR 6.58, 95% CI 1.82-23.8) were found to have optimal work ability. Anxiety (OR 4.93, 95% CI 1.76 to 13.76), and sub-optimal work ability (OR 4.22, 95% CI 1.39 to 12.77) were predictors of depression among survivors. Disease status and fatigue were associated with all three dimensions of survivorship in our study. CONCLUSION: Understanding survivorship will help improve health outcomes in this population. In our study, work ability, anxiety, depression, and their associated factors were found to be interrelated. Interventions in these areas can go a long way in improving breast cancer survivorship.

Intraindividual double burden of malnutrition among women (15-49 years) in India, Myanmar, and Nepal: evidence from the recent Demographic and Health Surveys.

BACKGROUND: There is a concurrent increase in anaemia and overweight/obesity among women in the South and South East Asia regions. Despite these, studies on the co-existence of anaemia and overweight/obesity in these countries are abysmally limited. This secondary analysis sought to estimate the burden of the intraindividual double burden of malnutrition (IDBM), i.e., co-existence of anaemia and overweight/obesity among women of reproductive age (15-49 years) in India, Myanmar, and Nepal, and explore the impact of socio-demographic and economic factors on this health outcome. METHODS: A secondary analysis of the Demographic and Health Surveys (DHS) of India (2019-2021), Myanmar (2015-2016), and Nepal (2016) was conducted. A descriptive analysis of the health outcomes and the risk factors was done with frequencies and percentages. The association between selected socio-demographic (women's age, education status, number of children and place of residence) and economic (occupation status, and wealth quintile) variables with IDBM was found with binary logistic regression analysis. RESULTS: Around one in ten women of reproductive age group in India and Myanmar had IDBM. In Nepal, it occurs in one in nearly 15 women. Maternal age, education, household wealth, number of children, place of residence, and occupation were found to be significant predictors of IDBM. CONCLUSION: There is a high prevalence of IDBM in South Asian women and it varies substantially across different socio-demographic and economic predictors. Sufficient evidence from prospective studies is needed to establish causal association and also to implement need-based prevention and curative strategies.

Budgetary allocation for health sector projects in local bodies with specific reference to noncommunicable diseases control.

Background: The role of local self-government (LSG) bodies in planning community-level interventions for noncommunicable diseases (NCD) control is critical. An understanding of how much priority is given to NCD in decentralized health planning is needed. Objective: The objective of this study is to analyze the pattern of budgetary allocation for health sector projects at different levels of LSGs in Thiruvananthapuram, Kerala, with specific reference to NCD control. Materials and Methods: Secondary data analysis was done on economic review reports and reports on health sector projects obtained from LSG department with permission. The pattern of budgetary allocation of health projects in both urban and rural local bodies of Thiruvananthapuram district for 2019-2020 was studied. Results: The proportion of NCD projects in terms of number and budget allocation, respectively, among health sector projects for gram panchayaths (GP) was 47 projects (5.25%) and 63.19 lakhs (1.8%). Figures for block panchayaths (BP) were 13 (9%) and 98.10 lakhs (10.94%), for district panchayath (DP), 1 (0.9%) and 48 lakhs (3%), for municipalities 1 (1.6%) and 4.66 lakhs (1.2%), and for corporation were 1 (1.4%) and 3 lakhs (0.16%). Only 29 (40%) GP and 5 (45%) BP had at least one NCD project. At the GP level, 21% of projects were community-based interventions and 15% of projects were for cancer screening, mental health, and hospital-based NCD clinics each. Among local bodies with lower allocation for NCD projects, the amount allocated for construction and maintenance work in health institutions was higher. Conclusion: Decision-making in decentralized health planning needs an evidence-based realignment of priorities toward NCD.

Patient Interval and Associated Factors in the Diagnostic Journey of Oral Cancer: A Hospital-Based Cross-Sectional Study from Kerala, India.

BACKGROUND: The incidence of oral cancer is increasing in south-central Asia. Though it can be detected early, most cases were reported in late stages, resulting in a poor prognosis. Reducing the patient interval will facilitate early diagnosis and better disease survival.  The paucity of research on the patient interval in oral cancer has limited our ability to design and evaluate programs for early diagnosis. METHODS: The study was conducted to identify the duration of patient interval and associated factors in oral cancer. Patients with oral cancer reporting at a tertiary cancer center during the study period were interviewed using validated data collection tools. The 'Aarhus statement' guidelines were followed in designing and reporting the study. RESULTS: Among the 261 participants, 54% reported a patient interval of more than 90 days. The median (IQR) patient interval was 92 (38-168) days. In the multivariate binary logistic regression model, those who approached healthcare facilities due to pain (OR, 8.3, 95% CI, 2.9 to 23.4) were more likely to have a patient interval of more than 90 days over those who came due to insistence by family. Smoking status (Current smoker vs. never smoker) at the time of diagnosis (OR, 2.518, 95% CI, 1.3 to 4.7), Stage of cancer (late vs. early) of participants (OR, 2.62, 95% CI, 1.3 to 5.2), and time of travel (>30 minutes vs. ≤ 10 minutes) to health care facility (OR 5.8, 95% CI, 1.6 to 21.7) were the other significant predict8  6766667ors for the patient interval of more than 90 days. CONCLUSION: Patient interval in oral cancer can be reduced by improving symptom awareness, abstinence from tobacco use, and facilitating access to health care facilities. The double burden of tobacco use in oral cancer, as it increases the risk of disease occurrence and delays symptom presentation, needs serious policy considerations in the context of cancer prevention.

The Catch-Up Growth in Stunted Children: Analysis of First and Second India Human Development Survey Data.

CONTEXT: Change in stunting as the children grow older is rarely found in published literature. AIMS: The present paper compares the change in the prevalence of stunting among children as they grow from 0-4 years to 7-11 years. SETTINGS AND DESIGN: The present paper is a secondary analysis of India Human Development Survey-I (IHDS-I) (2005) and IHDS-II (2012) data for Kerala. METHODS AND MATERIALS: In total, 411 children of age 0-4 years and 390 children of age 7-11 years with anthropometric measurements were included in the present study, respectively, from IHDS-I and IHDS-II. STATISTICAL ANALYSIS USED: The statistical analyses were done using SPSS 21.0. The prevalence of stunting was estimated. Bivariate and multivariate analyses were performed using the Pearson Chi-square test. RESULTS: The prevalence of stunting among children has been drastically reduced (50.4% to 20.3%) while growing older from 0-4 years to 7-11 years. CONCLUSIONS: More than half of the stunted children below 5 years regained normal growth, as they grow older.

The double burden of malnutrition: an assessment of 'stunted child and overweight/obese mother (SCOWT) pairs' in Kerala households.

A double burden of malnutrition (DBM) is the coexistence of under-nutrition and over-nutrition in a single household that has been reported from many developing countries. We performed a secondary analysis on India Human Development Survey (IHDS-II) data assessing 'stunted child and overweight/obese mother (SCOWT) pairs' in Kerala households. We included 344 pairs of children below 5 years of age and their mothers, with anthropometric measurements. We also performed the Pearson's Chi-square test to study the association of SCOWT pairs with socio-economic variables. The prevalence of SCOWT pairs was 10.7% for Kerala. The bivariate analysis showed no significant association for SCOWT pairs, irrespective of their socio-economic status. It is clear that the DBM is prevalent in Kerala and cannot be addressed exclusively by policies focusing on over-nutrition.

Community-based interventions for health promotion and disease prevention in noncommunicable diseases: A narrative review.

PURPOSE: Noncommunicable disease (NCD) prevention is emerging as a public health priority in developing countries. For better health outcome in these countries, it is necessary to understand the different community-based interventions developed and implemented across the world. OBJECTIVE: The objective of the current review is to identify the best strategies used in community-based health intervention (CBHI) programs across the world. MATERIALS AND METHODS: For review, we searched in PubMed and Google Scholar with the keywords "community based," "health interventions," "health promotions," "primary prevention," chronic diseases," "lifestyle-related diseases," and "NCD." Data were extracted using predesigned data extraction form. CBHI studies detailing their intervention strategies only were included in the review. RESULTS: Out of 35 articles reviewed, 14 (40%) were randomized control trials, while 18 (51.4%) were quasi-experimental design. Individual level (n = 14), group level (n = 5), community level (n = 6), and policy level (n = 4) intervention strategies were identified. Twenty-three (64%) studies were based on interventions for 1 year and above. Twenty-eight (80%) studies were intervened among specific populations such as Latinos and so on. CONCLUSION: Successful programs advocate for a package or a chain of interventions than a single intervention. The type of interventions at different levels, namely individual, group, community, and policy levels vary across studies, but individual, and group level interventions are more frequently used.

Seeking health under palm trees: Ayurveda in Kerala.

Movement for healthcare, mostly termed 'medical tourism', has been a sector of enormous potential in South Asia over the past years attracting many international clients. Kerala, a state in southern India, advertises 'Kerala Ayurveda' as one of its particular attractions. The objective of this paper is to study and understand the public health view on movements for healthcare and/or wellness across borders with a particular focus on the quality of treatments offered and on issues of ethics that concern patients from across different countries, but also the providers of Ayurveda treatments. To gain insights into local perspectives, interviews were conducted with Ayurveda practitioners at Ayurveda resorts in Kerala, in particular in Kovalam and Varkala, both in Thiruvananthapuram district. The analysis of our interviews shows that - perhaps not surprisingly in a world characterised by global capitalism - marketing plays an important role in attracting clients to resorts. Market considerations led to a transformation of how Ayurveda is presented to potential customers. This in turn has undermined the significance of Ayurveda within the tourism industry of Kerala. Arguably, representatives of the state view this as an opportunity rather than considering the importance of further developing Ayurveda as a medical practice.

Seven-year longitudinal change in risk factors for non-communicable diseases in rural Kerala, India: The WHO STEPS approach.

Nearly three-quarters of global deaths from non-communicable diseases (NCDs) occur in low- and middle-income countries such as India. However, there are few data available on longitudinal change in risk factors for NCDs in India. We conducted a cohort study among 495 individuals (aged 15 to 64 years at baseline) in rural Kerala state, India, from 2003 to 2010. For the present analysis, data from 410 adults (aged 20 to 64 years at baseline) who participated at both baseline and follow-up studies were analyzed. We used the World Health Organization STEPwise approach to risk factor surveillance for data collection. Age-adjusted change in risk factors for NCDs was assessed using the mixed-effects linear regression for continuous variables and the generalized estimating equation for categorical variables. The mean age of participants at baseline was 41.6 years, and 53.9% were women. The mean follow-up period was 7.1 years. There were significant increases in weight (mean change +5.0 kg, 95% confidence interval [CI] 4.2 to 5.8), body mass index (mean change +1.8 kg/m2, 95% CI 1.5 to 2.1), waist circumference (mean change +3.9 cm, 95% CI 3.0 to 4.8), waist-to-height ratio (mean change +0.022, 95% CI 0.016 to 0.027), current smokeless tobacco use (men: odds ratio [OR] 1.6, 95% CI 1.1 to 2.2), alcohol use (men: OR 2.6, 95% CI 1.9 to 3.5; women: OR 4.8, 95% CI 1.8 to 12.6), physical inactivity (OR 2.0, 95% CI 1.3 to 3.0), obesity (OR 2.2, 95% CI 1.7 to 2.8), and central obesity (OR 1.9, 95% CI 1.5 to 2.3). Over a seven-year period, several NCD risk factors have increased in the study cohort. This calls for implementation of lifestyle intervention programs in rural Kerala.

Exploring the Awareness Regarding E-waste and its Health Hazards among the Informal Handlers in Musheerabad Area of Hyderabad.

INTRODUCTION: Occupational Health hazards of handling and management of electronic waste is a nascent subject. Improper and unscientific handling of e-waste can invite significant human and environmental health risks. OBJECTIVE: To study the level of awareness about electronic waste and its health hazards amongst informal handlers in Musheerabad, Hyderabad. METHODOLOGY: Ethical approval and informed consents were obtained from Institutional Ethical Committee, University of Hyderabad and from the participants respectively before the commencement of study. This was a descriptive cross-sectional study conducted in randomly selected twenty-six waste handling centers from sixty of them in the locality. From each of the centers four handlers agedbetween 18 and 45 were randomly selected. Total of 104 handlers were interviewed using semi-structured schedule. Interviews were also conducted among 10 owners of such centres on the waste management practices. RESULTS: About 72% of the handlers did not know the meaning of electronic waste and 71% were not aware of associated health risks, 85% did not use any protective gears, while 16% acknowledged health issues attributed to improper handling of e-waste, 77% felt their handling of e-waste was appropriate. Majority of center owners felt that informal e-waste handling does not pose any health risks, and reported that there was no awareness campaign by any agency as of then. CONCLUSION: This study highlights the need for awareness campaigns on proper e-waste management practices to ensure occupational safety among the waste handlers who belong to lower socio-economic strata.

Utilization of Comprehensive Health Insurance Scheme, Kerala: A Comparative Study of Insured and Uninsured Below-Poverty-Line Households.

We aimed to compare the sociodemographics, health care utilization pattern, and out-of-pocket (OOP) expenses of 149 insured and 147 uninsured below-poverty-line households insured under the Comprehensive Health Insurance Scheme, Kerala, through a comparative cross-sectional study. Family size more than 4 (odds ratio [OR] = 2.34; 95% confidence interval [CI] = 1.13-4.82), family member with chronic disease (OR = 2.05; 95% CI = 1.18-3.57), high socioeconomic status (OR = 2.95; 95% CI = 1.74-5.03), and an employed household head (OR = 2.69; 95% CI = 1.44-5.02) were significantly associated with insured households. Insured households had higher inpatient service utilization (OR = 1.57; 95% CI = 1.05-2.34). Only 40% of inpatient service utilization among the insured was covered by insurance. The mean OOP expenses for inpatient services among insured (INR 448.95) was higher than among uninsured households (INR 159.93); P = .003. These findings show that urgent attention of the government is required to redesign and closely monitor the scheme.

A Risk Score to Predict Hypertension in Primary Care Settings in Rural India.

We used the data of 297 participants (15-64 years old) from a cohort study (2003-2010) who were free from hypertension at baseline, to develop a risk score to predict hypertension by primary health care workers in rural India. Age ≥35 years, current smoking, prehypertension, and central obesity were significantly associated with incident hypertension. The optimal cutoff value of ≥3 had a sensitivity of 78.6%, specificity of 65.2%, positive predictive value of 41.1%, and negative predictive value of 90.8%. The area under the receiver operating characteristic curve of the risk score was 0.802 (95% confidence interval = 0.748-0.856). This simple and easy to administer risk score could be used to predict hypertension in primary care settings in rural India.

Achutha Menon Centre Diabetes Risk Score: a type 2 diabetes screening tool for primary health care providers in rural India.

The authors aimed to develop a diabetes risk score for primary care providers in rural India. They used the baseline data of 451 participants (15-64 years) of a cohort study in a rural area of Kerala, India. The new risk score with age, family history of diabetes, and waist circumference identified 40.8% for confirmatory testing, had a sensitivity of 81.0%, specificity of 68.4%, positive predictive value of 37.0%, and negative predictive value of 94.0% for an optimal cutoff ≥4 with an area under the receiver operating characteristic curve of 0.812 (95% confidence interval = 0.765-0.860). The new risk score with 3 simple, easy-to-measure, less time-consuming, and less expensive variables could be suitable for use in primary care settings of rural India.

Incidence of tobacco use among adults (15-64 years) in rural Kerala.

We analyzed data from a cohort study in rural Kerala, India, to study the incidence of current smoking and current smokeless tobacco use. At baseline, of 452 individuals aged 15 to 64 years, 385 were current nonsmokers and 402 were current nonusers of smokeless tobacco. Over a mean follow-up of 7.1 ± 0.2 years, 5.5% became current smokers and 9.0% became current smokeless tobacco users. Among men, 21.1% (95% confidence interval [CI] = 11.1-36.4) of younger individuals (15-24 years) became current smokers and 22.2% (CI = 10.6-40.8) of older individuals (55-64 years) became current smokeless tobacco users. No women smoked both at baseline and at follow-up, but 9.7% (CI = 3.4-24.9) of older women (55-64 years) became current smokeless tobacco users. These findings call for effective implementation of India's Cigarettes and Other Tobacco Products Act, 2003.

Screening performance of diabetes risk scores among Asians and whites in rural Kerala, India.

We compared the screening performance of risk scores for Asians and whites for diabetes, dysglycemia, and metabolic syndrome. Our subjects were 451 people aged 15 to 64 years who participated in a cohort study from May 2003 through September 2010 in a rural area of the Thiruvananthapuram district of Kerala, India. All outcome measures showed overlap in the range of area under the receiver operating characteristic curves of Asian and white diabetes risk scores (DRSs). Asian and white DRSs performed similarly in rural India.

Untreated reproductive morbidities among ever married women of slums of Rajkot City, Gujarat: the role of class, distance, provider attitudes, and perceived quality of care.

It is a common problem in India for women in the reproductive age group to suffer from reproductive illnesses and not seek care. This paper is an attempt to assess untreated reproductive morbidities and to study factors affecting treatment-seeking behavior among ever married women of urban slums. We selected 1,046 women of the reproductive age group (15-49 years) using two-stage cluster sampling for a community-based, cross-sectional study. From this sample, 593 responses reporting reproductive morbidity were analyzed for treatment-seeking behavior and its correlates. Information was collected on demographics, socioeconomic status, self-reported reproductive morbidity, and treatment-seeking patterns, along with reasons for not utilizing available health services, all using a pretested, structured interview schedule. Univariate and multivariate analyses were done in SPSS 15.0. In our sample, 57% of women had at least one reproductive morbidity; of these, only one third sought health care. Women belonging to the Scheduled Castes/Scheduled Tribes caste group (OR = 3.92, 95% CI 1.44-10.64), at a distance of more than 2 km from a health facility (OR = 2.67, 95% CI 1.28-5.58), and whose duration of illness was more than 1 year (OR = 14.44, 95% CI 3.66-56.87) accessed fewer reproductive health services compared to their counterparts. The present study found that a lower sense of need, the cost of care, and societal barriers were the reasons for not seeking care. Providers' poor attitudes, poor quality of services, and long waiting times were found to be the reasons for not utilizing health facilities. The determinants for accessing reproductive health care were resources available at the household level, social factors, the availability of services, and behaviors related to health. Government facilities remained underutilized.