Anxiety, stress, and quality of life in patients with tuberculosis: A systematic review and meta-analysis.

Anxiety symptoms when coexisting with tuberculosis (TB), can have deleterious effects on treatment continuation that could contribute to the development of treatment resistance in TB. It is essential to understand the prevalence of anxiety in TB to develop clinical recommendations for its management. The primary objective of our review was to estimate the pooled prevalence of anxiety in TB patients along with the estimation of stress and quality of life in such patients. The relevant literature search on observational studies published in the English language till the year 2020 was carried out. A total of 8086 participants from 29 studies were included, of which 24 were cross-sectional studies and the remaining were case-control, and cohort studies. The estimated pooled prevalence of anxiety, comorbid depression, stress, and poor quality of life in TB patients was 32.54% [24.95, 41.18], 32.87% [25.79, 40.82], 52.68% [48.60, 56.72], and 79.51% [45.67, 94.72] respectively. When comparing the prevalence of anxiety across World Health Organization (WHO) regions, there was a statistically significant difference, with the African Region (AFR) having the highest prevalence i.e. 37.87% [29.59, 46.92], and the Western Pacific Region (WPR) having the lowest prevalence i.e. 15.83 % [12.72, 19.53]. The higher prevalence of anxiety in TB in the AFR and South-East Asian Region (SEAR) suggests a strong correlation with the developing status of these regions which calls for efforts to identify and treat the risk factors common to both anxiety and TB.

Musculoskeletal pain affecting undergraduate nursing students: A cross sectional study on the prevalence and the associated factors.

BACKGROUND: Musculoskeletal pain conditions (MSP) affect not only professional nurses but nursing students too. Long standing pain conditions affecting young individuals in their productive years can impact their work efficiency and can have economic impacts. Effective interventions to decrease the effect of MSP conditions are essential for a healthy professional nursing force which form the backbone of the healthcare system. PURPOSE: We conducted this study with an aim to estimate the prevalence and patterns of MSP conditions in undergraduate nursing students. Additionally, we attempted to evaluate the associated factors and identify the predictors of MSP conditions in them. METHODS: This cross-sectional study was conducted using a web-based electronic questionnaire on nursing students at a tertiary level teaching hospital. The questionnaire prepared on Kobo Toolbox was circulated among the students of each class by their class representative using WhatsApp and e-mail. Two reminders were sent at 24-hour intervals. The data were analysed to identify the prevalence of MSP and evaluate the probable associated factors. RESULTS: One hundred and seventy-nine out of 255 (70.2 %) participants responded and 173 consented for participation. Around 53.2 % participants had suffered from MSP in the past year. A total of 43.9 % of the participants had previously suffered from musculoskeletal pain even earlier than the past one-year in question. Those in their 2nd academic year had higher odds of suffering from MSP. Factors related to self-study after the formal teachings at the school/ college of nursing like the place, duration, and posture, and the pattern of usage of electronic devices like smartphones and laptop computers had no significant association with the MSP conditions. Lack of physical exercise, attending clinical placements, and the factors related to such placements like duration and frequency of placements, and the duration of breaks during any placement were noted to have an influence on MSP. CONCLUSION: More than 50 % students reported to be affected by MSP over a year. Association with factors like inadequate physical activity, and strenuous clinical placements identified in this study indicate that modifications in the nursing curriculum are required. Encouraging physical activity on one hand, while minimising exhaustive, and taxing clinical placements might be the way forward for improving the musculoskeletal health of aspiring nurses.

Experiences and Beliefs on Tobacco Use, Cessation in India: A Qualitative Study.

Background: Almost 80% of global tobacco usage is concentrated in low- and-middle-income countries (LMICs) like India. Added to this, there is dearth of dedicated tobacco cessation specialist services in healthcare settings in these regions. Identification of challenges in the delivery of cessation interventions and understanding the experiences of tobacco users will aid in formulating successful quit strategies. Objectives: This qualitative study in India aimed to understand the perspectives of tobacco-using patients in healthcare facilities regarding tobacco use and cessation. Methods: This qualitative study was conducted in urban and rural areas of four study sites, two each in the North and South India. Using purposive sampling, patients who were tobacco users were selected from healthcare facilities. The interviews were transcribed, coded and organised into themes. Analysis was done using NVivo 10 software. Results: A total of 22 in-depth interviews were conducted on participants aged 23 to 80 years who were either current or past tobacco users. A majority of the participants were aware of their increased health risks associated with tobacco consumption and had attempted quitting; however, barriers such as peer influence, formed habit, certain cultural barriers and the addictive nature of nicotine prevented them from successfully quitting. Familial and peer support, the government's role in spreading public awareness, and limiting the sale of tobacco were stated as facilitators for tobacco cessation. Conclusions: The findings of this study point out that despite awareness of the perils of tobacco among smokers, there are various barriers and beliefs related to tobacco use and cessation. These findings would prove advantageous for policy-makers to implement and promote addiction treatment programmes for successful tobacco cessation efforts. In order to optimise strategies, policies must be well informed by ongoing dialogue between the public, service providers and policy-makers.

COVID-Somnia: A Multicentric Study on Sleep Disturbances During the COVID-19 Pandemic With Spatial Mapping of Hotspots.

Objective The purpose of this study was to document sleep quality and assess its sociodemographic, behavioral (i.e., tobacco use, alcohol use, and screen time), and mental-health-related indicators (i.e., anxiety and depression) in adults aged 30-59 years across three states of India, and to geo-locate state and district-level findings of sleep quality during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Methods From October 2020 to April 2021, residents (aged 30-59 years) of Kerala, Madhya Pradesh, and Delhi completed a web-based survey that included sociodemographic and behavioral factors, clinical history of COVID-19, and mental health screening instruments for anxiety and depression, namely the Generalized Anxiety Disorder 2-item (GAD-2) and Patient Health Questionnaire-2 (PHQ-2). The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate the quality of sleep. Average PSQI scores were geo-mapped. Results Of the 694 participants who responded, 647 completed the PSQI. The mean (SD) global PSQI score was 5.99 (3.2), with approximately 54% of participants reporting poor sleep quality (PSQI Score>5). Eight hotspot districts with severe sleep disturbances (mean score PSQI>6.5) were identified. Multivariable logistic regression analysis showed that compared to Madhya Pradesh, participants from Kerala and Delhi had 62% and 33% lower chances of having poor sleep quality, respectively. Those who screened positive for anxiety had higher odds of having poor sleep quality (adjusted odds ratio {aOR}=2.4, P=0.006*). Conclusion Overall, sleep quality was poor during the early stages of the COVID-19 pandemic (October 2020-April 2021), especially among those who reported high levels of anxiety. Among the three included states, there were differences in sleep quality.

Exploring the determinants of workplace mental health in a medical institution in central India: A cross-sectional survey.

Introduction: Mental health at the workplace (WMH) is an important indicator for the optimum functioning of a medical institute. To establish an effective WMH, it is essential to understand the level of awareness, perceptions, and felt needs of students and staff of a medical institute regarding mental health services within the campus. Material and Methods: A cross-sectional web-based survey was conducted in an institution of national importance in Central India using a semistructured questionnaire based on Kobo Toolbox. Felt need for periodic mental health screening within the institutional campus (FN-S) and felt need of having a separate cell for mental healthcare of students and employees (FN-C) were analyzed using univariable and multivariable logistic regression. Results: A total of 526 out of 2190 eligible students and staff completed the survey (response rate 24.1%). About half of the participants were not aware, of whom to contact on campus in case of mental health concerns (MHCs), more than three-fourths were not aware of the rights for seeking treatment, and three-fourths thought that getting diagnosed with an MHC would negatively impact their academic course or work. There was a high felt need for mental health screening services (91.1%), and almost two-thirds felt the need for a separate mental health cell. The FN-S was higher among those from rural areas, those not using social media, those without a preexisting MHC, and those without FN-C. FN-C was higher in those not using social media, those having sleep disturbances, those with unawareness of the rights of a mentally ill person, those without any MHC, and those not having FN-S. Conclusion: Active efforts are needed to roll out a mental health screening policy and separate mental health cells within the medical institute. Future research should focus on a qualitative inquiry into the details of the above findings.

Can proactive roles played by Community Medicine professionals in times of COVID-19 Pandemic bring the leadership of public health in India in the right hands?

Since the onset of the COVID-19 Pandemic, various public health measures have been in focus, viz. social distancing, hand hygiene, use of masks, screening of patients for COVID-19 symptoms, development of quarantine and isolation facilities, and public health surveillance. Most of these relate to the principles of prevention, early case detection, and primary care. In the ongoing fight against COVID-19, community medicine (CM) professionals are involved at various positions and have been leading from the front in a variety of activities, be it screening, patient care, surveillance, orientation and training of front line workers, community engagement, evidence generation through research, and development of guidelines. However, their engagement in policymaking has still been limited. The government should work more closely with CM professionals in order to stem the tide of COVID-19 or any such public health emergencies in the future by shifting the focus to preventive and promotive interventions. CM professionals should take a more proactive approach in getting involved in policymaking and demonstrate leadership through their actions to lead the national, state, and district-level public health teams through collaboration across disciplines and sectors. This will help bring the leadership of public health in India in the right hands for optimum population health and appropriate and timely health emergency response.

Neck pain among undergraduate medical students in a premier institute of central India: A cross-sectional study of prevalence and associated factors.

CONTEXT: Competitive exams conducted for undergraduate and postgraduate medical courses in India are tough. The undergraduate course is additionally taxing to the students' health. Lack of physical activity, the stress of studies, and universal adoption of different gadgets make the undergraduate medical students prone to develop musculoskeletal pain-related issues. AIMS: This study aimed to evaluate the prevalence of neck pain and the associated factors including gadget use among undergraduate medical students of a premier medical college in central India. SETTINGS AND DESIGN: All undergraduate medical students including the interns of our institute were enrolled for this cross-sectional study. METHODS AND MATERIALS: A self-explanatory internet-based questionnaire prepared using Kobo Toolbox was circulated via WhatsApp and email by the class representative of each batch of students. The responses obtained were analyzed using Statistical Package for the Social Sciences (SPSS). STATISTICAL ANALYSIS USED: Proportions and means were calculated. Chi-square test and univariable logistic regression analysis were used. RESULTS: Three hundred thirty-one valid responses out of 423 responses were analyzed. In total, 58.3% of 331 students suffered from neck pain within the last one year. Students in the 3rd and 4th year had 2.9 times higher odds of current neck pain in comparison to 1st-year students. History of neck pain before joining the course was associated with a higher risk of having current neck pain. Self-perceived aggravation of pain from gadget use had significantly higher odds of contributing to the current episode of neck pain. CONCLUSIONS: Neck pain is not uncommon among undergraduate medical students. History of previous neck pain including that during schooling makes a student prone for the current episode of pain. Academic stress, smartphone and laptop use tend to aggravate the pain in those who have neck pain.

Awareness and perceptions regarding taxation and health warnings related to sugar-sweetened beverages and the factors associated with these among visitors of a general out-patient clinic in Bhopal, India.

INTRODUCTION: Although increased taxation on sugar-sweetened beverages (SSBs) and warning labels on their packaging have been successful in other countries, India has not implemented these. It is imperative to understand the user perspectives before implementation, regarding which almost no information exists. OBJECTIVES: To assess the awareness and perceptions of people regarding taxation and health warnings on SSB packaging, and to determine the factors associated with these. METHODOLOGY: This cross-sectional study was conducted in the general out-patient clinic of a public tertiary care hospital in Bhopal, India, between April and November 2018. Patients and accompanying persons ≥15 years of age and attending the clinic were included. Severely ill patients were excluded. Exit interviews were conducted after the clinical consultation using a pre-tested semi-structured interview schedule. Data were analyzed using IBM SPSS version 21. RESULTS: Out of the 503 participants interviewed, three-fourths had never heard of taxes on SSBs and had never seen any health warning on SSB packaging. Most participants (96.6%) wanted some health warning to be present on the packaging. Majority of them (69.3%) wanted both textual and pictorial warnings. Close to half of those who wanted a pictorial warning to be present opined that it should occupy <25% of the surface area of the packaging. Multivariable analysis showed that participants aged <25 years and females were not in favor of tax increment. CONCLUSION: Government policies should also focus on user perspectives and preferences before deciding to increase tax on SSBs or introducing mandatory health warnings on SSBs.

Young, obese, and underweight patients show up inadequately at scheduled appointments: Findings from a record-based study on diabetic, hypertensive diabetic, and hypertensive patients attending a primary care clinic of Puducherry.

BACKGROUND: One key barrier to proper management of common cardio-metabolic conditions such as diabetes and hypertension in primary care is inadequate adherence to treatment, which, in many cases, results from inadequate follow-up at scheduled appointments. In addition to provider and health system level factors, individual patient level factors are also associated with attendance at follow-up appointments. OBJECTIVE: To document the association of diabetic, hypertensive diabetic, and hypertensive patient's demographic and clinical factors with showing up inadequately at scheduled appointments. METHODS: A record-based retrospective follow-up study was conducted in an urban primary health center of Puducherry from January to March 2015. Registered diabetic, hypertensive diabetic, and hypertensive patients who made at least one visit between July and December 2014 were included. Data on demographic factors, clinical factors, and dates of visits to the clinic were collected from case records of patients and were entered in EpiData entry version 3.1. Analysis was performed using R statistical package. RESULTS: Out of 366 patients, 79% were females and 70.2% were aged >50 years. It was found that 183 (50%) were diabetic, 266 (72.7%) were hypertensive, and 115 (31.4%) were hypertensive diabetic. Out of 366 patients, all the five follow-up visits were attended by 185 (50.6%) patients, and "adequate follow-up" was found in 123 (33.6%) patients. Young, underweight, and obese patients were more likely to have inadequate follow-up. CONCLUSION: Family physicians should give special attention to these groups in their routine practice along with providing targeted health education and implementing full proof mechanisms to track them.

Depression, anxiety, and bodily pain independently predict poor sleep quality among adult women attending a primary health center of Puducherry, India.

BACKGROUND: Sleep disorders and mental health problems are common diagnoses in primary care settings. The objective of this study was to estimate the magnitude of poor sleep, depression, and anxiety through opportunistic screening and to find out the independent predictors of poor sleep quality among female participants. MATERIALS AND METHODS: A hospital-based study was conducted in the outpatient department (OPD) of an urban primary health center of Puducherry. Patients and accompanying healthy attendants ≥ 18 years of age who visited the OPD for any reason were included. Those with serious acute illness, previously diagnosed mental illness, pregnant women, and women in postpartum period (upto 6 weeks) were excluded. Systematic random sampling was used to select the participants. A semi-structured questionnaire was used to collect sociodemographic and clinical details along with the Pittsburgh Sleep Quality Index (PSQI) and the Hospital Anxiety and Depression Scale. Height and weight were also measured. RESULTS: A total of 301 participants were recruited. Mean age of the participants was 49.4 (standard deviation 15.2) years. Magnitude of poor sleep (PSQI score > 5), abnormal anxiety, and abnormal depression were 118 (39.2%), 60 (19.9%), and 28 (9.3%) respectively. Multivariate logistic regression analysis showed that history of pain [odds ratio (OR) 3.2 (1.6-6.5), P = 0.001], abnormal anxiety [OR 2.5 (1.2-5.6), P = 0.021], and abnormal depression [OR 4.3 (1.4-13.2), P = 0.01] independently predicted poor sleep quality among females. CONCLUSION: OPD-based opportunistic screening for sleep and mental health problems should be routinely conducted by primary care and family physicians.

Epidemiological Study of Patients of Road Traffic Injuries Attending Emergency Department of a Trauma Center in New Delhi.

BACKGROUND AND AIMS: There is paucity of data regarding some of the lesser known contextual and epidemiological factors with respect to road traffic injuries (RTIs). The objective was to study the epidemiological profile of RTI victims attending an emergency department of a tertiary care trauma center. METHODS: The present study was a hospital-based cross-sectional study conducted in the emergency department of a tertiary care trauma center in New Delhi. All patients of RTI attending the emergency department during the designated data collection days were included in the study. Patients brought dead were excluded from the study. A semi-structured interview schedule was developed for collecting data on various domains such as sociodemographic characteristics, vehicle-related factors, accident site-related factors, personal protection measures, contextual factors, and prehospital care-related factors. RESULTS: A total of 984 patients and informants were approached and finally data of 900 participants were analyzed after excluding those who refused participation and those for whom incomplete data were available. Out of 900 RTI victims, 756 were male (84.0%) and 144 (16.0%) were female. Mean age of the victims was 32.7 years. Most of the victims, i.e., 377 out of 900 (41.9%) were occupants rather than drivers. Majority of victim's vehicle meeting accidents were motorized two-wheelers (53.4%), and majority of the colliding vehicle was a four-wheeler (39.3*). Helmet use was found to be low (63.3%), but seat belt use was particularly low (32.4%). Most accidents (28%) happened between midnight and 6 A.M. More than half of the victims were in a hurry on the day of the accident. An ambulance was used to transport the victims in only 14.6% cases. CONCLUSION: In road traffic accidents some lesser known epidemiological data were generated that may be useful in defining preventive measures.

Awareness of health warnings and factors predicting awareness and perceived effectiveness of pictorial health warnings on tobacco products among adults in rural Puducherry, India.

BACKGROUND: Limited information exists in India about the awareness and perception of the people regarding pictorial health warnings (PHWs) and text warnings on tobacco products, more so from rural areas. Objectives were to report the awareness of these warnings, factors predicting awareness and perceived effectiveness of PHWs, and understanding of their content in a rural population. MATERIALS AND METHODS: A community-based cross-sectional study was conducted in two villages (chosen randomly out of total four) in the rural field practice area of a tertiary care teaching hospital in Puducherry. Households were selected by systematic random sampling. All persons ≥18 years and residing in the area for at least 6 months were included. Data regarding awareness and perception of participants was collected through a semi-structured interview schedule. RESULTS: A total of 428 participants were recruited; 197 (46%) were male, and 231 (54%) were female. The mean age of the participants was 38.9 (standard deviation 15.0) years. Awareness of PHWs and text warnings was 39.5% (169/428) and 21% (90/428), respectively. Only 11.2% participants perceived PHWs as effective. Most (45%) of the participants had a vague understanding of the content of PHWs. On multivariate logistic regression, male gender, current tobacco use, and better education emerged as predictors of greater awareness of PHWs. Extended family predicted greater perceived effectiveness of PHWs, whereas, high socioeconomic class and middle school completion predicted lower perceived effectiveness of PHWs. CONCLUSION: Awareness and perceived effectiveness of adults in rural Puducherry regarding PHWs were low. There is a need to create awareness through education and using meaningful, larger pictures.

Prevalence of nonalcoholic fatty liver disease in an adult population in a rural community of Haryana, India.

BACKGROUND: Though nonalcoholic fatty liver disease (NAFLD) is increasingly becoming prevalent in the Indian population, knowledge regarding the burden and risk factors of NAFLD is limited, more so from rural areas. This study was thus conducted to estimate the prevalence of NAFLD among adults in a rural community of Haryana, India and to measure the association of diet, physical activity, and other selected risk factors with NAFLD. MATERIALS AND METHODS: The present study was conducted in a rural community of Haryana, India among resident adults ≥35 years of age. Eight out of 28 villages were selected by probability proportion to size sampling. The number of eligible and consenting participants randomly selected from each village was 27. Out of 216 participants thus recruited, 184 participants reported for undergoing ultrasonography (USG) of the liver, anthropometry, blood pressure recording, and blood sample collection. Finally, 176 participants were analyzed. RESULTS: Prevalence of NAFLD was 30.7%. There was no significant difference in the calorie intake and average total physical activity between participants with and without NAFLD. On multivariate analysis, hypertension [adjusted odds ratio (OR): 2.3, 95% confidence interval (CI): 1.1-5.0, P 0.03] and an increased waist circumference (adjusted OR: 4.9, 95% CI: 1.5-7.0, P < 0.001) were independently associated with NAFLD. A normal high-density lipoprotein (HDL) level was protective against NAFLD (adjusted OR: 0.4, 95% CI: 0.2-0.8, P 0.001). CONCLUSIONS: The high prevalence of NAFLD is already a public health problem, even in the rural parts of India. Urgent public health interventions are required to prevent its development by controlling the cardiometabolic risk factors associated with it.

Improper sharp disposal practices among diabetes patients in home care settings: Need for concern?

In the recent years, outbreaks of blood-borne infections have been reported from assisted living facilities, which were traced back to improper blood glucose monitoring practices. Needle-stick injuries have been implicated in many such cases. This directly raises concerns over sharp disposal practices of diabetic patients self-managing their condition in home care settings. With India being home to a huge diabetic population, this issue, if neglected, can cause substantial damage to the health of the population and a marked economic loss. This article discusses the sharp disposal practices prevalent among diabetes patients, the importance of proper sharp disposal, barriers to safe disposal of sharps, and the options available for doing the same. For adopting an environmentally safe wholesome approach, disposal of plastics generated as a result of diabetes self-care at home is important as well. The article also looks at the possible long-term solutions to these issues that are sustainable in an Indian context.

mHealth in the Prevention and Control of Non-Communicable Diseases in India: Current Possibilities and the Way Forward.

Mobile health technology has been used effectively for healthcare delivery in many developing countries. India is currently facing an epidemic of Non-Communicable Diseases (NCDs). With greater availability of cheaper phones in the market, the user base of mobile phones in India is increasing rapidly. The present review was thus conducted to explore the current possibilities and future scope of mobile health for NCD prevention and control in India. Literature search was conducted using MEDLINE, EMBASE, and Cochrane Library to collect information regarding mobile health interventions. Two authors extracted the data and included studies if at least the abstract was available. Information from key reports and government websites were also included. We examined information from domains such as need for mobile health in NCDs in India, and the advantages, scope and challenges of mobile health for healthcare delivery in India. Existing mobile health systems in India, current evidence of mobile health use in NCDs, and the recent mobile health related initiatives taken by Government of India were also assessed. Though we found some examples of current mobile phone usage in many health related programmes in India, data from mobile health research is scarce, particularly for NCDs. The current evidence base needs to be strengthened. There is also a need for identifying various opportunities in the recent initiatives taken by Government of India. It can be concluded that though mobile health has many advantages, there are numerous challenges which need to be addressed before scaling it up at the national level.

Prevalence of acute respiratory infection among under-five children in urban and rural areas of puducherry, India.

INTRODUCTION: The incidence of Acute respiratory infections (ARI) is high among under-five children, especially in developing countries. However, the data on ARI from rural and urban areas in India are scarce. OBJECTIVE: To estimate the prevalence of ARI and selected associated factors among under-five children. MATERIALS AND METHODS: A community-based cross-sectional study was conducted in urban and rural areas of Puducherry, India. Data were collected from 509 parents of under-five children regarding ARI incidence along with socio-demographic and selected associated factors. RESULTS: Overall prevalence of ARI was observed to be 59.1%, with prevalence in urban and rural areas being 63.7% and 53.7%, respectively. Bivariate analysis indicated that overcrowding, place of residence, and mother's education were significantly associated with ARI. Multiple logistic regression analysis suggested that presence of overcrowding (adjusted odds ratio [AOR] = 1.492), urban residence (AOR = 2.329), and second birth order (AOR = 0.371) were significant predictors of ARI. CONCLUSION: The prevalence of ARI is high, particularly in urban areas. Improvement of living conditions may help in reduction of burden of ARI in the community.

Quality of Life (QOL) and Its Associated Factors Using WHOQOL-BREF Among Elderly in Urban Puducherry, India.

BACKGROUND: Quality of Life (QOL) among elderly is a neglected issue especially in developing countries including India. AIM: To assess the QOL and its associated factors among elderly population. MATERIALS AND METHODS: A community based cross-sectional study was conducted among 300 elderly subjects in urban Puducherry, India. Data on QOL was assessed by World Health Organization Quality of Life BREF (WHOQOL-BREF) and Activities of Daily Living (ADLs) by Katz ADL scale. Socio-demographic factors and chronic morbid conditions were recorded by using structured questionnaire. STATISTICAL ANALYSIS: Independent sample test and multiple linear regression analysis. RESULTS: Majority (64%, 192) were in the (60-69) years' age-group. Overall mean Standard Deviation (SD) score of QOL was 49.74 (10.21). QOL was significantly low among those with no schooling, nuclear family, not receiving pension, not with partner, having musculoskeletal disorder, low vision and impaired ADL groups in univariate analysis. Multiple linear regression analysis revealed that older age (p=0.014), no schooling (p=0.004), without spouse (p=<0.001), nuclear family (p=0.039), musculoskeletal disorder (p=<0.001), low vision (p=0.049) and hearing impairment (0.001) were associated with low QOL score. CONCLUSION: QOL score among elderly is average, while social relationship domain of QOL score was found to be low. Health education with regard to activity and environmental changes and increase in social relationship may help in improving the QOL among the elderly population.