TONE UP THE MUSCLES AND BUILD AN ATTRACTIVE PHYSIQUE
ANKUR BARUA, M.A. BASILIO
Department of Community Medicine, Sikkim-Manipal Institute of Medical Sciences (SMIMS), Sikkim, India
Contact Address of the Corresponding Author:
Dr. ANKUR BARUA
BLOCK – EE, No. – 80, FLAT No. – 2A,
SALT LAKE CITY, SECTOR – 2,
KOLKATA – 700 091.
WEST BENGAL, INDIA
Email: ankurbarua26@yahoo.com
Tel: +91-33-23215586
Mobile: +919434485543.
TONE UP THE MUSCLES AND BUILD AN ATTRACTIVE PHYSIQUE
Introduction
Many people want to have nice muscle tone and an attractive physique, but they often do not want to have big muscles and a muscular body. So they just lift lightweights with high repetitions. But this is not very effective, as we need to first build up our muscle bulk before toning them down into good shapes. So, in the first step, we need to lift heavy weight at regular intervals in order to force our muscles to grow.
Once we are satisfied with the size of our muscles, we need to cut our subcutaneous pad of fats for muscles to show up well. This is the second step to develop nice muscle tone for shaping an attractive physique. However, we need to have a firm commitment and knowledge to build an attractive muscular body and develop nice muscle tone. Before we commence weight training, we need to warm up and do some stretching exercises.
Train with Free Weights
All professional body builders almost exclusively use free weights. At the beginning of body building exercises we need to concentrate on free weights and work exclusively with barbells and dumb bells. Free weights recruit many stabilizing muscles for balance and control. That means we shall work a lot more muscle parts other than the intended ones. This will give rise to little bumps, striations and definitions all over your body instead of one huge lump of muscle on your intended muscle. Because of this extra stimulant created, our muscles will grow faster too.
Train with Compound Exercises
We should always try to incorporate as many compound exercises as possible to our routines. Compound exercises are exercises that involve 2 or more joint movements. Because they utilize more joints, greater muscle mass is involved. Involvement of greater muscle mass is equivalent to work with heavier weights. Heavier weights mean encouragement of greater muscle growth. Greater muscle growth means more tone to your muscles. The examples of some excellent compound exercises are the Squat, Deadlift, Chin ups, Dips, Bench press, Barbell Press, Lunges and Bent-Over Barbell Row.
Train Intensively Avoiding Over-strain
We must train intensively for our muscles to grow and try to do more repetitions or add more weight than the previous session. It is important that every time we train hard, we should also give our body enough time to recover as it has suffered strains and actually sustained many small scarring. Our muscles grow when we rest, due to the effect of growth hormones, especially when we sleep. So, we need to sleep at least 8 hours a day. There is no need to train everyday. We should work the same muscle group only once or twice a week. If the training is vigorous enough, we should not exercise for more than an hour per session. The cardio work should be directed at cutting body fat in order to develop the muscle tone. During the muscle-building phase, we should do less cardio work as the aerobic exercises burn muscles bulk. So, we should not do cardio work on the same day as our weight lifting work.
Technique and Form
This is the most neglected fundamental of bodybuilding. Everywhere, everyday, we can see people using wrong forms and techniques. This not only compromises our growth, but also makes us susceptible to injuries. Deformity occurs usually when people try to lift weights that are too heavy. So, we should always lift weight with strict focus on that particular exercise for the muscle, which we intend to build. So, we should be careful enough to lift the weights deliberately and slowly. We should never swing our weights up especially while doing bicep curls or the military press.
Perform Lower Body Exercises
This is what most people never realize. Our lower body makes up about (60-70)% of our musculature. It is unfortunate that most people often do not train their legs. If we do not train the muscles of our lower extremities then, not only we shall appear spider-legged, but also our entire body will stop growing large.
The intensity of training the muscles of our lower extremities will produce more growth hormones when we sleep and the overall muscular development will be stimulated. Our body shape will also be more balanced and therefore more attractive.
Thursday, January 7, 2010
Sunday, October 25, 2009
BIOETHICS OF STEM CELL RESEARCH AND CLONING
This is a preview version. To order the complete book, please visit “Bookstore” of website: http://www.unibook.com
Or Click on: http://www.unibook.com/unibook/site/bookdetail/?bookid=8365
BIOETHICS OF STEM CELL RESEARCH AND CLONING
ANKUR BARUA, ROMILA SYANGDEN
Sikkim-Manipal University of Health, Medical and Technological Sciences
Gangtok, Sikkim, India 2009
Background: Dr. Ankur Barua had graduated with distinction from the University of Hong Kong (MBuddStud, 2009). He had also completed two other Master Degrees, one from Sikkim Manipal University (MBAIT, 2007) while the other from Manipal University (MBBS-2000, MD in Community Medicine - 2003) and presently working in professional field.
Ms. Romila Syangden is a Hospital Administration professional who has also a keen passion for conducting research on public health, religion and science.
First Publication on 26th October 2009
Sikkim Manipal University of Health, Medical and Technological Sciences, Sikkim, India
Copyright © Ankur Barua and Romila Syangden
Communication Address of Corresponding Author:
Dr. ANKUR BARUA
Block – EE, No.-80, Flat No.-2A,
Salt Lake City, Sector-2,
Kolkata - 700091, West Bengal, INDIA.
Email: ankurbarua26@yahoo.com
Mobile: +91-9434485543 (India), +852-96195078 (Hong Kong)
BIOETHICS OF STEM CELL RESEARCH AND CLONING
SYNOPSIS
Introduction
Stem cells are blank cells that have the potential to develop into any type of cell in the body. Scientists are trying to harvest the cells before they have differentiated, then coax them into becoming certain types. These cell lines are colonies of embryonic stem cells of different types. There is a rapid and astonishing progress in the field of cloning since the making of “Dolly” – the first cloned sheep, a few years ago.
Advantages of Stem Cell Research and Cloning Technology
The Stem Cell Research may lead to cloning a whole human being. In that case, if we can accept surrogate motherhood as an ethically acceptable process, cloning is more or less the same. Cloned individuals need not be necessarily being identified with the donor. Even identical twins are different from each other, influenced by environment and other psycho-social factors. During cloning of various organs and bone marrow transplants, these organs would be an exact genetic match of the recipient and so there will be no rejection.
Disadvantages of Stem Cell Research and Cloning Technology
Every form of reproductive technology raises the question of human values, dignity, worth, jurisdictional rights. A person should not be used as a mere mechanical instrument. Human being is an unrepeatable entity. Cloned embryo may undergo mutation and can lead to the creation of a monster instead of a human being. Natural birth is a product of human love. In cloning, the values of love and human procreation are missing. It violates the principle of equality among human beings and principle of non-discrimination through selective eugenic dimension used for specific cloning.
Conclusions
The clone’s sense of self-worth or individuality or dignity would be difficult to sustain. From the religious perspectives Judaism and Islam support most forms of Stem Cell Research and Cloning. The Vatican has expressed sadness and dismay at the proposal for this human cloning venture by stating that this process of cloning violates the right of a human being to be conceived in human way. Buddhist Bioethics also discourages cloning technology due to the fact that there is no limit to human ambitions and no strict judicious control over Stem Cell Research and Cloning in many countries of the world.
Key words: Stem Cell, Cloning, Bioethics, Research, Theological, Religious
BIOETHICS OF STEM CELL RESEARCH AND CLONING
INTRODUCTION
Stem cells are blank cells that have the potential to develop into any type of cell in the body. Scientists are trying to harvest the cells before they have differentiated, then coax them into becoming certain types. These cell lines are colonies of embryonic stem cells of different types. Stem cells are one of the human body's master cells, with the ability to grow into any one of the body's more than 200 cell types.
All stem cells are unspecialized (undifferentiated) cells that are characteristically of the same family type (lineage). They retain the ability to divide throughout life and give rise to cells that can become highly specialized and take the place of cells that die or are lost.
Stem cells contribute to the body's ability to renew and repair its tissues. Unlike mature cells, which are permanently committed to their fate, stem cells can both renew themselves as well as create new cells of whatever tissue they belong to (and other tissues).
Bone marrow stem cells, for example, are the most primitive cells in the marrow. From them all the various types of blood cells are descended. Bone marrow stem-cell transfusions (or transplants) were originally given to replace various types of blood cells.
The concept of this kind of research was believed to be in the minds of the Indians since long back. The Adi-Parva of Mahabharata gives clear indication that the kauravas were born from the stem cells. Human cloning means the asexual replication of a human individual by taking of cells with genetic materials and cultivation of these cells through egg, embryo and finally into human being.
There is a rapid and astonishing progress in the field of cloning since the making of “Dolly” – the first cloned sheep, a few years ago. “George” and “Charlie”, the two identical, genetically engineered calves that could make medicines in their milk were also successfully created. While “dolly” was cloned from a cell taken from an adult mammal, “Charlie” and “George” were cloned from cells taken from fetuses which are an easier process.
OBJECTIVES
(1) To study the various ethical issues related to Stem Cell Research and Cloning.
(2) To study the theological aspects of Stem Cell Research and Cloning.
REVIEW OF LITERATURE
About Stem Cells
Broadly speaking, a stem cell is one that–in the course of cell division and increase in the numbers of cells–is able to reproduce itself and also mature into various specialized types of cells. The stem cell with the greatest potential (totipotential) is the fertilized egg cell, which is capable of developing into a complete organism.
According to the usual–but actually very doubtful–explanation, the fertilized egg cell has totipotential up to the stage of division into eight cells, and in later stages the cells retain only "pluripotential." That is, they can form many different types of tissues, but not the complete organism. Embryonic stem cells–that is, those 50 cells within a blastocyst, which then continue to develop into the embryo proper–have this pluripotential. In the course of further specialization, stem cells of individual tissues are formed, such as that of the bone marrow, from which all the other kinds of blood cells develop.
Behind this description lies the conception that a linear process of differentiation is played out, in the development of the individual, toward increasingly "mature," specialized cells in the individual tissues, from totipotentiality to tissue specificity. This process is supposed to run only forward, but never backward. That is, as soon as a cell has reached a certain degree of "maturity," the way back to earlier stages of development is closed off. So it is evident that a stem cell’s capacity to perform is increasingly limited to specific functions, and it loses, correspondingly, the manifold capabilities still present in earlier developmental stages.
According to latest reports, however, this dogma of developmental biology does not hold. Evidently, tissue-specific stem cells have the ability–as has been impressively demonstrated in experiments with animals–to "transdifferentiate" themselves when in a different environment–that is, to take on the cell functions of the new tissue. Thus, neuronal stem cells of mice have transformed themselves into blood stem cells and produced blood cells. Indeed, there are indications of another capability of adult stem cells: Apparently they have the potential to be "reprogrammed." Not only can they adjust to the specific conditions of a new tissue environment, but they can even assume more generalized, earlier levels of development, so that it even appears possible that they become totipotent again.
Concept of Stem Cell Research and Cloning
Stem cells can divide for an infinite period of time when being grown outside of the body, and which can differentiate into various types of specialized cells. When fertilization of an egg with sperm occurs, the resulting fertilized cell has the capability to form an entire organism. The cell is described as being totipotent (having total potential). After some time, as rounds of cell division occur, specialization of cells occurs. But, early in fetal development, before the developing mass of cells attaches itself to the wall of the uterus, some cells still retain the ability to form virtually every type of cell in the body. These cells are pluripotent (capable of differentiating into many types of cells but not all types required for fetal development). With continued fetal development, further specialization of pluripotent stem cells results in multipotent stem cells--cells that give rise to cells having a particular function, such as blood cells and various types of skin cells. Stem Cell Research is concerned primarily with the pluripotent cells. The field is relatively new. James Thomson reported in Science in late 1998 his success in maintaining undifferentiated embryonic stem cells in their undifferentiated state in lab culture.
Stem cells can be obtained from human embryos at the so-called blastocyst stage (a stage very early in fetal development, only a few division cycles after fertilization). As well, cells can be obtained from fetal tissue from terminated pregnancies. The latter procedure has precipitated much discourse. In August 2001, United States president George W. Bush announced that he would support very limited federal funding of research using stem cells from human embryos. It was a compromise that did not completely satisfy parties on either side of the controversial issue.
Another potential means of obtaining pluripotent stem cells may be a technique called somatic cell nuclear transfer. In the technique involves the physical removal of its nucleus from an egg cell. The nucleus is the specialized area of the cell that contains the organized pieces of genetic material called the chromosomes. The material left behind in the egg cell contains nutrients and other energy-producing materials necessary for development of the embryo. Then, a somatic cell--any cell other than an egg or a sperm cell--is placed next to the denucleated egg cell, and the two cells are chemically fused together. After a requisite number of cell divisions, pluripotent stem cells can be recovered and used.
Pluripotent stem cells are important to science and to advances in health care. At the most fundamental level, study of these cells could advance the understanding of the processes of cellular development, such as the orchestrated mechanisms by which genes are turned on and off during development and growth. Some of the most serious medical conditions, such as cancer and birth defects, are due to abnormal cell specialization and cell division. Pluripotent stem cells could also be used to screen new drugs, eliminating the need to use living subjects for the early phases of drug discovery.
The most far-reaching potential application of the stem cells is the generation of cells and tissue that could be used for so-called cell therapies. Potentially stem cells may function as a kind of universal human donor cell, which could serve as raw material for whatever diseased cell requires replacing. Such donor cells would have to be genetically engineered so as not to form the cell surface molecules that would alert the recipient's immune system. The cells could be used for replacement of defective or diseased cells without the danger of transplantation rejection that occurs presently. Potential applications include the replacement of defective heart tissue and replacement of malfunctioning insulin producing cells in Type I diabetes.
In the last several years, several lines of research have produced concrete results showing the potential of stem cells in cell therapy. Genetic engineering of stem cells may be promising as a cancer eradication strategy. In rats, neural stem cells genetically engineered to convert a compound into a cancer-killing agent have been found to selectively target and destroy cancerous cells in the brain. Elsewhere, neural stem cells have also been shown capable of integration into the diseased retina of rats and of taking on some of the characteristics of retinal cells. This holds the promise that stem cell therapy may aid in repairing retinal damage. Other researchers have demonstrated, again in rats, that stem cells in the brain were able to repair damaged areas and restore function when stimulated by a growth-inducing protein. If replicated in humans, then stem cell treatments for stroke, nervous system and spinal cord injury and diseases such as Parkinson's and Alzheimer's that are marked by degeneration of nerve cells.
Another application of stem cells has been to form a chimera—an animal that grows from an embryo in which stem cells from another animal have been inserted. Some of the chimera's cells have one set of parents, and some cells have another set of parents. "Knockout" mice, research animals lacking specific genes, are chimeras. While theoretically conceivable, human chimeras are not contemplated.
Researchers have claimed success at reprogramming multipotent cells for a function other than that they were programmed for. Specifically, adult skin cells from cattle were reverted to stem cells and then transformed into heart cells. Other studies involved neural stem cells from mice and bone marrow cells from rats have also indicated that functional reprogramming of adult cells may be feasible. These breakthrough studies hold forth the potential of using cells from adults to treat diseases, rather than extracting embryonic cells.
There are several barriers to the use of adult stem cells at present. First of all, more knowledge of the locations of adult stem cells is still required since these cells might not be present in all tissues of the body. Secondly, adult stem cells are present in minute quantities, are difficult to isolate and their number decreases with age. The time necessary to locate, harvest, and grow the cells to usable numbers may be too long for practical purposes. Finally, adult stem cells may contain DNA abnormalities, which have accumulated as a result of a lifetime of exposure to DNA-altering agents such as sunlight and toxic chemicals. Further research may overcome these limitations, allowing stem cells obtained from adults to be used in cell therapy.
Stem cells from bone marrow can also, quite remarkably, give rise to non-marrow cells. In a 1999 report in the journal Nature, scientists from Boston led by Dr. Louis M. Kunkel reported that they gave bone marrow transplants from normal mice to dystrophic mice. Some 12 weeks later about 10% of the muscle fibers in the diseased animals were making the correct form of dystrophin, the protein that is defective in Duchenne muscular dystrophy. This work suggests that bone marrow stem cells may offer new ways of treating muscular dystrophy (and other non-blood diseases).
CONCLUSION FROM THE THEOLOGICAL ASPECT OF STEM CELL RESEARCH AND CLONING
From the religious perspectives, it is interesting to note that, the religions that have strong traditions of legal and religious law, namely Judaism and, Islam support most forms of Stem Cell Research. These two religions also support their beliefs on when life begins and Stem Cell Research by interpreting specific religious texts. While the Catholic Church has put the issue of Stem Cell Research on the forefront of its agenda, Pope John Paul II does not point to any specific biblical text that supports the Catholic Church’s concept of when life begins.
However, since religion can exert influence over the public and politicians, specifically, when it comes to moral arguments; religions such as Judaism and Islam need to be more vocal in their support of Stem Cell Research to balance out Catholicism’s almost blanket prohibition of the medical advance.
While science may never answer the question of when life begins, Catholicism, Judaism and Islam have answered the question in some ways that support and in other ways that prohibit the use of stem cells, even for therapeutic means. Since, there are no limits to human ambitions and no strict judicious control over Stem Cell Research; cloning technology for any purpose is never encouraged according to the Buddhist Bioethics.
Or Click on: http://www.unibook.com/unibook/site/bookdetail/?bookid=8365
BIOETHICS OF STEM CELL RESEARCH AND CLONING
ANKUR BARUA, ROMILA SYANGDEN
Sikkim-Manipal University of Health, Medical and Technological Sciences
Gangtok, Sikkim, India 2009
Background: Dr. Ankur Barua had graduated with distinction from the University of Hong Kong (MBuddStud, 2009). He had also completed two other Master Degrees, one from Sikkim Manipal University (MBAIT, 2007) while the other from Manipal University (MBBS-2000, MD in Community Medicine - 2003) and presently working in professional field.
Ms. Romila Syangden is a Hospital Administration professional who has also a keen passion for conducting research on public health, religion and science.
First Publication on 26th October 2009
Sikkim Manipal University of Health, Medical and Technological Sciences, Sikkim, India
Copyright © Ankur Barua and Romila Syangden
Communication Address of Corresponding Author:
Dr. ANKUR BARUA
Block – EE, No.-80, Flat No.-2A,
Salt Lake City, Sector-2,
Kolkata - 700091, West Bengal, INDIA.
Email: ankurbarua26@yahoo.com
Mobile: +91-9434485543 (India), +852-96195078 (Hong Kong)
BIOETHICS OF STEM CELL RESEARCH AND CLONING
SYNOPSIS
Introduction
Stem cells are blank cells that have the potential to develop into any type of cell in the body. Scientists are trying to harvest the cells before they have differentiated, then coax them into becoming certain types. These cell lines are colonies of embryonic stem cells of different types. There is a rapid and astonishing progress in the field of cloning since the making of “Dolly” – the first cloned sheep, a few years ago.
Advantages of Stem Cell Research and Cloning Technology
The Stem Cell Research may lead to cloning a whole human being. In that case, if we can accept surrogate motherhood as an ethically acceptable process, cloning is more or less the same. Cloned individuals need not be necessarily being identified with the donor. Even identical twins are different from each other, influenced by environment and other psycho-social factors. During cloning of various organs and bone marrow transplants, these organs would be an exact genetic match of the recipient and so there will be no rejection.
Disadvantages of Stem Cell Research and Cloning Technology
Every form of reproductive technology raises the question of human values, dignity, worth, jurisdictional rights. A person should not be used as a mere mechanical instrument. Human being is an unrepeatable entity. Cloned embryo may undergo mutation and can lead to the creation of a monster instead of a human being. Natural birth is a product of human love. In cloning, the values of love and human procreation are missing. It violates the principle of equality among human beings and principle of non-discrimination through selective eugenic dimension used for specific cloning.
Conclusions
The clone’s sense of self-worth or individuality or dignity would be difficult to sustain. From the religious perspectives Judaism and Islam support most forms of Stem Cell Research and Cloning. The Vatican has expressed sadness and dismay at the proposal for this human cloning venture by stating that this process of cloning violates the right of a human being to be conceived in human way. Buddhist Bioethics also discourages cloning technology due to the fact that there is no limit to human ambitions and no strict judicious control over Stem Cell Research and Cloning in many countries of the world.
Key words: Stem Cell, Cloning, Bioethics, Research, Theological, Religious
BIOETHICS OF STEM CELL RESEARCH AND CLONING
INTRODUCTION
Stem cells are blank cells that have the potential to develop into any type of cell in the body. Scientists are trying to harvest the cells before they have differentiated, then coax them into becoming certain types. These cell lines are colonies of embryonic stem cells of different types. Stem cells are one of the human body's master cells, with the ability to grow into any one of the body's more than 200 cell types.
All stem cells are unspecialized (undifferentiated) cells that are characteristically of the same family type (lineage). They retain the ability to divide throughout life and give rise to cells that can become highly specialized and take the place of cells that die or are lost.
Stem cells contribute to the body's ability to renew and repair its tissues. Unlike mature cells, which are permanently committed to their fate, stem cells can both renew themselves as well as create new cells of whatever tissue they belong to (and other tissues).
Bone marrow stem cells, for example, are the most primitive cells in the marrow. From them all the various types of blood cells are descended. Bone marrow stem-cell transfusions (or transplants) were originally given to replace various types of blood cells.
The concept of this kind of research was believed to be in the minds of the Indians since long back. The Adi-Parva of Mahabharata gives clear indication that the kauravas were born from the stem cells. Human cloning means the asexual replication of a human individual by taking of cells with genetic materials and cultivation of these cells through egg, embryo and finally into human being.
There is a rapid and astonishing progress in the field of cloning since the making of “Dolly” – the first cloned sheep, a few years ago. “George” and “Charlie”, the two identical, genetically engineered calves that could make medicines in their milk were also successfully created. While “dolly” was cloned from a cell taken from an adult mammal, “Charlie” and “George” were cloned from cells taken from fetuses which are an easier process.
OBJECTIVES
(1) To study the various ethical issues related to Stem Cell Research and Cloning.
(2) To study the theological aspects of Stem Cell Research and Cloning.
REVIEW OF LITERATURE
About Stem Cells
Broadly speaking, a stem cell is one that–in the course of cell division and increase in the numbers of cells–is able to reproduce itself and also mature into various specialized types of cells. The stem cell with the greatest potential (totipotential) is the fertilized egg cell, which is capable of developing into a complete organism.
According to the usual–but actually very doubtful–explanation, the fertilized egg cell has totipotential up to the stage of division into eight cells, and in later stages the cells retain only "pluripotential." That is, they can form many different types of tissues, but not the complete organism. Embryonic stem cells–that is, those 50 cells within a blastocyst, which then continue to develop into the embryo proper–have this pluripotential. In the course of further specialization, stem cells of individual tissues are formed, such as that of the bone marrow, from which all the other kinds of blood cells develop.
Behind this description lies the conception that a linear process of differentiation is played out, in the development of the individual, toward increasingly "mature," specialized cells in the individual tissues, from totipotentiality to tissue specificity. This process is supposed to run only forward, but never backward. That is, as soon as a cell has reached a certain degree of "maturity," the way back to earlier stages of development is closed off. So it is evident that a stem cell’s capacity to perform is increasingly limited to specific functions, and it loses, correspondingly, the manifold capabilities still present in earlier developmental stages.
According to latest reports, however, this dogma of developmental biology does not hold. Evidently, tissue-specific stem cells have the ability–as has been impressively demonstrated in experiments with animals–to "transdifferentiate" themselves when in a different environment–that is, to take on the cell functions of the new tissue. Thus, neuronal stem cells of mice have transformed themselves into blood stem cells and produced blood cells. Indeed, there are indications of another capability of adult stem cells: Apparently they have the potential to be "reprogrammed." Not only can they adjust to the specific conditions of a new tissue environment, but they can even assume more generalized, earlier levels of development, so that it even appears possible that they become totipotent again.
Concept of Stem Cell Research and Cloning
Stem cells can divide for an infinite period of time when being grown outside of the body, and which can differentiate into various types of specialized cells. When fertilization of an egg with sperm occurs, the resulting fertilized cell has the capability to form an entire organism. The cell is described as being totipotent (having total potential). After some time, as rounds of cell division occur, specialization of cells occurs. But, early in fetal development, before the developing mass of cells attaches itself to the wall of the uterus, some cells still retain the ability to form virtually every type of cell in the body. These cells are pluripotent (capable of differentiating into many types of cells but not all types required for fetal development). With continued fetal development, further specialization of pluripotent stem cells results in multipotent stem cells--cells that give rise to cells having a particular function, such as blood cells and various types of skin cells. Stem Cell Research is concerned primarily with the pluripotent cells. The field is relatively new. James Thomson reported in Science in late 1998 his success in maintaining undifferentiated embryonic stem cells in their undifferentiated state in lab culture.
Stem cells can be obtained from human embryos at the so-called blastocyst stage (a stage very early in fetal development, only a few division cycles after fertilization). As well, cells can be obtained from fetal tissue from terminated pregnancies. The latter procedure has precipitated much discourse. In August 2001, United States president George W. Bush announced that he would support very limited federal funding of research using stem cells from human embryos. It was a compromise that did not completely satisfy parties on either side of the controversial issue.
Another potential means of obtaining pluripotent stem cells may be a technique called somatic cell nuclear transfer. In the technique involves the physical removal of its nucleus from an egg cell. The nucleus is the specialized area of the cell that contains the organized pieces of genetic material called the chromosomes. The material left behind in the egg cell contains nutrients and other energy-producing materials necessary for development of the embryo. Then, a somatic cell--any cell other than an egg or a sperm cell--is placed next to the denucleated egg cell, and the two cells are chemically fused together. After a requisite number of cell divisions, pluripotent stem cells can be recovered and used.
Pluripotent stem cells are important to science and to advances in health care. At the most fundamental level, study of these cells could advance the understanding of the processes of cellular development, such as the orchestrated mechanisms by which genes are turned on and off during development and growth. Some of the most serious medical conditions, such as cancer and birth defects, are due to abnormal cell specialization and cell division. Pluripotent stem cells could also be used to screen new drugs, eliminating the need to use living subjects for the early phases of drug discovery.
The most far-reaching potential application of the stem cells is the generation of cells and tissue that could be used for so-called cell therapies. Potentially stem cells may function as a kind of universal human donor cell, which could serve as raw material for whatever diseased cell requires replacing. Such donor cells would have to be genetically engineered so as not to form the cell surface molecules that would alert the recipient's immune system. The cells could be used for replacement of defective or diseased cells without the danger of transplantation rejection that occurs presently. Potential applications include the replacement of defective heart tissue and replacement of malfunctioning insulin producing cells in Type I diabetes.
In the last several years, several lines of research have produced concrete results showing the potential of stem cells in cell therapy. Genetic engineering of stem cells may be promising as a cancer eradication strategy. In rats, neural stem cells genetically engineered to convert a compound into a cancer-killing agent have been found to selectively target and destroy cancerous cells in the brain. Elsewhere, neural stem cells have also been shown capable of integration into the diseased retina of rats and of taking on some of the characteristics of retinal cells. This holds the promise that stem cell therapy may aid in repairing retinal damage. Other researchers have demonstrated, again in rats, that stem cells in the brain were able to repair damaged areas and restore function when stimulated by a growth-inducing protein. If replicated in humans, then stem cell treatments for stroke, nervous system and spinal cord injury and diseases such as Parkinson's and Alzheimer's that are marked by degeneration of nerve cells.
Another application of stem cells has been to form a chimera—an animal that grows from an embryo in which stem cells from another animal have been inserted. Some of the chimera's cells have one set of parents, and some cells have another set of parents. "Knockout" mice, research animals lacking specific genes, are chimeras. While theoretically conceivable, human chimeras are not contemplated.
Researchers have claimed success at reprogramming multipotent cells for a function other than that they were programmed for. Specifically, adult skin cells from cattle were reverted to stem cells and then transformed into heart cells. Other studies involved neural stem cells from mice and bone marrow cells from rats have also indicated that functional reprogramming of adult cells may be feasible. These breakthrough studies hold forth the potential of using cells from adults to treat diseases, rather than extracting embryonic cells.
There are several barriers to the use of adult stem cells at present. First of all, more knowledge of the locations of adult stem cells is still required since these cells might not be present in all tissues of the body. Secondly, adult stem cells are present in minute quantities, are difficult to isolate and their number decreases with age. The time necessary to locate, harvest, and grow the cells to usable numbers may be too long for practical purposes. Finally, adult stem cells may contain DNA abnormalities, which have accumulated as a result of a lifetime of exposure to DNA-altering agents such as sunlight and toxic chemicals. Further research may overcome these limitations, allowing stem cells obtained from adults to be used in cell therapy.
Stem cells from bone marrow can also, quite remarkably, give rise to non-marrow cells. In a 1999 report in the journal Nature, scientists from Boston led by Dr. Louis M. Kunkel reported that they gave bone marrow transplants from normal mice to dystrophic mice. Some 12 weeks later about 10% of the muscle fibers in the diseased animals were making the correct form of dystrophin, the protein that is defective in Duchenne muscular dystrophy. This work suggests that bone marrow stem cells may offer new ways of treating muscular dystrophy (and other non-blood diseases).
CONCLUSION FROM THE THEOLOGICAL ASPECT OF STEM CELL RESEARCH AND CLONING
From the religious perspectives, it is interesting to note that, the religions that have strong traditions of legal and religious law, namely Judaism and, Islam support most forms of Stem Cell Research. These two religions also support their beliefs on when life begins and Stem Cell Research by interpreting specific religious texts. While the Catholic Church has put the issue of Stem Cell Research on the forefront of its agenda, Pope John Paul II does not point to any specific biblical text that supports the Catholic Church’s concept of when life begins.
However, since religion can exert influence over the public and politicians, specifically, when it comes to moral arguments; religions such as Judaism and Islam need to be more vocal in their support of Stem Cell Research to balance out Catholicism’s almost blanket prohibition of the medical advance.
While science may never answer the question of when life begins, Catholicism, Judaism and Islam have answered the question in some ways that support and in other ways that prohibit the use of stem cells, even for therapeutic means. Since, there are no limits to human ambitions and no strict judicious control over Stem Cell Research; cloning technology for any purpose is never encouraged according to the Buddhist Bioethics.
START YOUR RESEARCH PROJECT NOW
This is a preview version. To order the complete book, please visit “Bookstore” of website: http://www.unibook.com
Or Click on: http://www.unibook.com/unibook/site/bookdetail/?bookid=8351
START YOUR RESEARCH PROJECT NOW
Dr. ANKUR BARUA
MBBS, MD (Community Medicine), MBAIT, MBuddStud (Hong Kong)
Hong Kong, 2009
Background:
The author had graduated with distinction from the University of Hong Kong (MBuddStud, 2009). He had also completed two other Master Degrees, one from Sikkim Manipal University (MBAIT, 2007) while the other from Manipal University (MBBS-2000, MD in Community Medicine - 2003) and presently working in professional field.
First Publication on 26th October 2009
Sikkim Manipal University of Health Medical and Technological Sciences
Copyright © Ankur Barua
Address for communication:
Dr. ANKUR BARUA
Block – EE, No.-80, Flat No.-2A,
Salt Lake City, Sector-2,
Kolkata - 700091, West Bengal, INDIA.
Email: ankurbarua26@yahoo.com
Mobile: +91-9434485543 (India), +852-96195078 (Hong Kong)
Contents
Items Page No.
Acknowledgements 04
Preface 05
Framework of a Research Project
(a) Introduction, Objectives 06
(b) Review of Literature 07
(c) Materials and Methods 08
(d) Overview of Major Study Designs in Health Research 10
(e) Selection of an Appropriate Study Design 12
(f) Sample Size Estimation 13
(g) Sampling Procedure 15
(h) Study Instruments 17
(i) Organization of Field Work and Plan for Data Collection 17
(j) Study Variables 18
(k) Data Analysis 18
Basic Algorithms of Statistical Tests of Significance
(a) Parametric Tests 20
(b) Non-Parametric Tests 21
Summary Statistics for Continuous Variables 23
Normal Distribution Curve 24
Dummy Tables 24
Summary & Conclusions, Limitations, Recommendations, References 27
Annexure 28
Final Revision, Formatting and Preparation of the Research Project Report 29
Summary of Micro-Planning of Health Research Protocol / Report Presentation 30
Concluding Remarks by the Author 31
Acknowledgements
I would like to express my sincere gratitude to my beloved father Dr. Dipak Kumar Barua, who was the earlier Dean of the Faculty Council for Postgraduate Studies in Education, Journalism & Library Science in the University of Calcutta (1987-1991) and the Director of Nava Nalanda Mahavihara, Nalanda (1996-1999) for his technical guidance and valuable advice throughout the compilation of this handbook.
I would also like to convey my sincere thanks to my mother Mrs. Dipa Barua and Ms. Mary Anne Basilio for their constant encouragement, keen interest and support throughout this project.
Preface
This book provides first-hand guidance and adequate information on publication in indexed journals. Due to paucity of space in most of the indexed journals, researchers are advised to be stringent with the use of language and make an attempt to express the maximum information by using optimum words in their research reports. This book is a simplified version and a ready guide on how to frame and conduct a health research, analyze the data and present the final report in an effective manner.
Ankur Barua
FRAMEWORK OF A RESEARCH PROJECT
1) INTRODUCTION
a) Problem Statement of Incidence / Prevalence:
In World – with recent studies
In India – with recent examples
In Locality – with recent examples
b) Psycho–Socio–Demographic correlates identified by the WHO or any other renowned indexed journal.
c) Defending the need for study and how researchers as well as community can benefit from this study.
2) OBJECTIVES
a) Clear cut and well defined easily measurable quantitatively:
Max 5 objectives but prefer to restrict the study within 3 objectives.
b) If ≥5 objectives are to be mentioned, then set an AIM by combining the statements and meanings of one or two main objectives. The objectives should address & clarify the following points –
Define study design
Define study population
Define study area
Study Period (not mandatory)
Define main outcome variable (department variable)
Define Risk factors / Psycho–Socio–Demographic correlates
Define comparison groups
[* Please do remember that each objective mentioned here, has to be addressed independently in the results section]
3) REVIEW OF LITERATURE
a) Global Burden of Disease and DALYs lost due to the diseased condition under scrutiny
b) ICD–10 Disease Clarification for the disease to be studied
c) Case Definition according to ICD-10 and Operational Case Definition
d) Problem Statement in detail –
Incidence or Prevalence of the disease in World
Incidence or Prevalence of the disease in India
Incidence or Prevalence of the disease in Locality
Give a table showing major studies conducted in the world and in India. Mention in chronological order of studies preferably from a Meta-analysis if available:
Sl. No. Name of Chief Investigator Study Period Study Area Sample
Size Incidence or Prevalence Rates Instrument / Diagnostic Criteria
EXAMPLE
Sl. No. CHIEF INVESTIGATOR/
FIRST AUTHOR YEAR STUDY AREA SAMPLE
SIZE PREVALENCE OF DEPRESSIVE DISORDERS
(%) INSTRUMENT/
DIAGNOSTIC CRITERIA
1. Fuhrer 1992 France 2792 13.6 CES-D
2. Kua 1992 Singapore 612 5.7 GMS-AGECAT
3. Madianos 1992 Greece 251 27.1 CES-D
4. Henderson 1993 Australia 945 1.0 CIE
5. Ihara 1993 Japan 695 5.3 CES-D
6. Saunders 1993 UK 5222 10.0 GMS-AGECAT
e) Socio – demographic correlates – examples from previous studies conducted
f) Associated co-morbid conditions – examples from previous studies conducted
g) Defining other parameters needs to be measured from the study instruments other than outcome variable e.g., QOL, Wellbeing, Cognitive impairment.
h) Defining the age cut off for selection of study population
i) Any National Health Programme associated with the study outcome
History of the National Health Programme associated with the disease
Any National Health Policy associated with the disease
Review & critical evaluation of the National Health Programme associated with the disease
Goals set for control or eradication of the diseased condition in future / recent years
Any suggestions / recommendations to improve the services under the national programme associated with the disease by renowned authors / researchers
j) Discussion on problems with field surveys in India –
Sampling errors
Case definition
Classification of Disease (standard)
Statistical Analysis
Training of investigators
4) MATERIALS & METHODS
Materials & Methods should provide the following information:
a) BACKGROUND INFORMATION –
Geographical location with map of India and local map of study area
Numbers of Province / Districts / Taluks
Total population of Province / Districts / Taluks
Socio–cultural– demographical profile of the study population
Health care providers in study area
b) STUDY PERIOD Data collection time
c) SETTING Study area
d) STUDY DESIGN Choose the appropriate study design based on need of the study
e) STUDY POPULATION Sample size estimation
f) SAMPLING PROCEDURE done to avoid sampling error in selecting participants of the study
g) STUDY INSTRUMENTS
Acceptability, Validity & Reliability after Pre-testing or conducting a Pilot Study
Translation, Back Translation & Re-Translation of study instruments
h) ORGANIZATION OF FIELD WORK AND PLAN FOR DATA COLLECTION
Training of investigators & participating volunteers for data collection on how to collect un-biased information by interview technique or questionnaire method
Mention the actual data collection procedure with sequence of administration of each questionnaire including time management
Vocational / Medical / Financial benefits offered to the study subjects after providing valuable information on research topic
i) STUDY VARIABLES provide a list of study variables in annexure
j) PLAN FOR DATA ANALYSIS Mention the Statistical Software Package used & level of significance
SUMMARY OF MICRO-PLANNING OF HEALTH RESEARCH PROTOCOL / REPORT PRESENTATION
A. Title page: Title of research, Institution symbol, Name of principal author(s) & Date
B. Certificate from University duly signed by Guide & Co- Guide
C. Certificate from the respective department duly signed by Guide & Co- Guide
D. Certificate from HOD of the respective department
E. Acknowledgements:
HOD of department undertaking the project
Guide
Co- Guide
Others for significant contribution and moral support.
Other department heads involved / staffs involved
Participants of this study / research.
F. Structured Abstract (Brief report after completion of the project):
1) Title of the project
2) Name of all authors (surname first)
3) Name of Institute where the study is conducted
4) Introduction
5) Objectives
6) Materials & Methods
7) Results & Discussion
8) Summary & Conclusions (including implications for nursing care if applicable)
9) Limitations / Recommendations
10) Key words (3 to 5 in number)
G. Body of Contents of research project in details:
1) Introduction
2) Objectives
3) Review of Literature
4) Materials & Methods
5) Results & Discussion
6) Summary & Conclusions (including implications for nursing care if applicable)
7) Limitations & Recommendations
8) References
9) Annexure
Concluding Remarks by the Author
The objective of this handbook is to present the basic concepts of epidemiology and Biostatistics in an attempt to provide the reader with a practical application of the concepts. This book will help the reader to select appropriate methods and study designs to conduct a research and also to correctly analyze any database for information.
Or Click on: http://www.unibook.com/unibook/site/bookdetail/?bookid=8351
START YOUR RESEARCH PROJECT NOW
Dr. ANKUR BARUA
MBBS, MD (Community Medicine), MBAIT, MBuddStud (Hong Kong)
Hong Kong, 2009
Background:
The author had graduated with distinction from the University of Hong Kong (MBuddStud, 2009). He had also completed two other Master Degrees, one from Sikkim Manipal University (MBAIT, 2007) while the other from Manipal University (MBBS-2000, MD in Community Medicine - 2003) and presently working in professional field.
First Publication on 26th October 2009
Sikkim Manipal University of Health Medical and Technological Sciences
Copyright © Ankur Barua
Address for communication:
Dr. ANKUR BARUA
Block – EE, No.-80, Flat No.-2A,
Salt Lake City, Sector-2,
Kolkata - 700091, West Bengal, INDIA.
Email: ankurbarua26@yahoo.com
Mobile: +91-9434485543 (India), +852-96195078 (Hong Kong)
Contents
Items Page No.
Acknowledgements 04
Preface 05
Framework of a Research Project
(a) Introduction, Objectives 06
(b) Review of Literature 07
(c) Materials and Methods 08
(d) Overview of Major Study Designs in Health Research 10
(e) Selection of an Appropriate Study Design 12
(f) Sample Size Estimation 13
(g) Sampling Procedure 15
(h) Study Instruments 17
(i) Organization of Field Work and Plan for Data Collection 17
(j) Study Variables 18
(k) Data Analysis 18
Basic Algorithms of Statistical Tests of Significance
(a) Parametric Tests 20
(b) Non-Parametric Tests 21
Summary Statistics for Continuous Variables 23
Normal Distribution Curve 24
Dummy Tables 24
Summary & Conclusions, Limitations, Recommendations, References 27
Annexure 28
Final Revision, Formatting and Preparation of the Research Project Report 29
Summary of Micro-Planning of Health Research Protocol / Report Presentation 30
Concluding Remarks by the Author 31
Acknowledgements
I would like to express my sincere gratitude to my beloved father Dr. Dipak Kumar Barua, who was the earlier Dean of the Faculty Council for Postgraduate Studies in Education, Journalism & Library Science in the University of Calcutta (1987-1991) and the Director of Nava Nalanda Mahavihara, Nalanda (1996-1999) for his technical guidance and valuable advice throughout the compilation of this handbook.
I would also like to convey my sincere thanks to my mother Mrs. Dipa Barua and Ms. Mary Anne Basilio for their constant encouragement, keen interest and support throughout this project.
Preface
This book provides first-hand guidance and adequate information on publication in indexed journals. Due to paucity of space in most of the indexed journals, researchers are advised to be stringent with the use of language and make an attempt to express the maximum information by using optimum words in their research reports. This book is a simplified version and a ready guide on how to frame and conduct a health research, analyze the data and present the final report in an effective manner.
Ankur Barua
FRAMEWORK OF A RESEARCH PROJECT
1) INTRODUCTION
a) Problem Statement of Incidence / Prevalence:
In World – with recent studies
In India – with recent examples
In Locality – with recent examples
b) Psycho–Socio–Demographic correlates identified by the WHO or any other renowned indexed journal.
c) Defending the need for study and how researchers as well as community can benefit from this study.
2) OBJECTIVES
a) Clear cut and well defined easily measurable quantitatively:
Max 5 objectives but prefer to restrict the study within 3 objectives.
b) If ≥5 objectives are to be mentioned, then set an AIM by combining the statements and meanings of one or two main objectives. The objectives should address & clarify the following points –
Define study design
Define study population
Define study area
Study Period (not mandatory)
Define main outcome variable (department variable)
Define Risk factors / Psycho–Socio–Demographic correlates
Define comparison groups
[* Please do remember that each objective mentioned here, has to be addressed independently in the results section]
3) REVIEW OF LITERATURE
a) Global Burden of Disease and DALYs lost due to the diseased condition under scrutiny
b) ICD–10 Disease Clarification for the disease to be studied
c) Case Definition according to ICD-10 and Operational Case Definition
d) Problem Statement in detail –
Incidence or Prevalence of the disease in World
Incidence or Prevalence of the disease in India
Incidence or Prevalence of the disease in Locality
Give a table showing major studies conducted in the world and in India. Mention in chronological order of studies preferably from a Meta-analysis if available:
Sl. No. Name of Chief Investigator Study Period Study Area Sample
Size Incidence or Prevalence Rates Instrument / Diagnostic Criteria
EXAMPLE
Sl. No. CHIEF INVESTIGATOR/
FIRST AUTHOR YEAR STUDY AREA SAMPLE
SIZE PREVALENCE OF DEPRESSIVE DISORDERS
(%) INSTRUMENT/
DIAGNOSTIC CRITERIA
1. Fuhrer 1992 France 2792 13.6 CES-D
2. Kua 1992 Singapore 612 5.7 GMS-AGECAT
3. Madianos 1992 Greece 251 27.1 CES-D
4. Henderson 1993 Australia 945 1.0 CIE
5. Ihara 1993 Japan 695 5.3 CES-D
6. Saunders 1993 UK 5222 10.0 GMS-AGECAT
e) Socio – demographic correlates – examples from previous studies conducted
f) Associated co-morbid conditions – examples from previous studies conducted
g) Defining other parameters needs to be measured from the study instruments other than outcome variable e.g., QOL, Wellbeing, Cognitive impairment.
h) Defining the age cut off for selection of study population
i) Any National Health Programme associated with the study outcome
History of the National Health Programme associated with the disease
Any National Health Policy associated with the disease
Review & critical evaluation of the National Health Programme associated with the disease
Goals set for control or eradication of the diseased condition in future / recent years
Any suggestions / recommendations to improve the services under the national programme associated with the disease by renowned authors / researchers
j) Discussion on problems with field surveys in India –
Sampling errors
Case definition
Classification of Disease (standard)
Statistical Analysis
Training of investigators
4) MATERIALS & METHODS
Materials & Methods should provide the following information:
a) BACKGROUND INFORMATION –
Geographical location with map of India and local map of study area
Numbers of Province / Districts / Taluks
Total population of Province / Districts / Taluks
Socio–cultural– demographical profile of the study population
Health care providers in study area
b) STUDY PERIOD Data collection time
c) SETTING Study area
d) STUDY DESIGN Choose the appropriate study design based on need of the study
e) STUDY POPULATION Sample size estimation
f) SAMPLING PROCEDURE done to avoid sampling error in selecting participants of the study
g) STUDY INSTRUMENTS
Acceptability, Validity & Reliability after Pre-testing or conducting a Pilot Study
Translation, Back Translation & Re-Translation of study instruments
h) ORGANIZATION OF FIELD WORK AND PLAN FOR DATA COLLECTION
Training of investigators & participating volunteers for data collection on how to collect un-biased information by interview technique or questionnaire method
Mention the actual data collection procedure with sequence of administration of each questionnaire including time management
Vocational / Medical / Financial benefits offered to the study subjects after providing valuable information on research topic
i) STUDY VARIABLES provide a list of study variables in annexure
j) PLAN FOR DATA ANALYSIS Mention the Statistical Software Package used & level of significance
SUMMARY OF MICRO-PLANNING OF HEALTH RESEARCH PROTOCOL / REPORT PRESENTATION
A. Title page: Title of research, Institution symbol, Name of principal author(s) & Date
B. Certificate from University duly signed by Guide & Co- Guide
C. Certificate from the respective department duly signed by Guide & Co- Guide
D. Certificate from HOD of the respective department
E. Acknowledgements:
HOD of department undertaking the project
Guide
Co- Guide
Others for significant contribution and moral support.
Other department heads involved / staffs involved
Participants of this study / research.
F. Structured Abstract (Brief report after completion of the project):
1) Title of the project
2) Name of all authors (surname first)
3) Name of Institute where the study is conducted
4) Introduction
5) Objectives
6) Materials & Methods
7) Results & Discussion
8) Summary & Conclusions (including implications for nursing care if applicable)
9) Limitations / Recommendations
10) Key words (3 to 5 in number)
G. Body of Contents of research project in details:
1) Introduction
2) Objectives
3) Review of Literature
4) Materials & Methods
5) Results & Discussion
6) Summary & Conclusions (including implications for nursing care if applicable)
7) Limitations & Recommendations
8) References
9) Annexure
Concluding Remarks by the Author
The objective of this handbook is to present the basic concepts of epidemiology and Biostatistics in an attempt to provide the reader with a practical application of the concepts. This book will help the reader to select appropriate methods and study designs to conduct a research and also to correctly analyze any database for information.
Friday, October 23, 2009
PREVALENCE OF NASAL CARRIAGE OF METHICILLIN RESISTANT STAPHYLOCOCCI IN HEALTHY POPULATION OF GANGTOK, EAST SIKKIM
JIMSA October-December 2008 Vol. 21 No. 4 191
ORIGINAL
PREVALENCE OF NASAL CARRIAGE OF METHICILLIN RESISTANT
STAPHYLOCOCCI IN HEALTHY POPULATION OF GANGTOK,
EAST SIKKIM
DEVJYOTI MAJUMDAR, ANKUR BARUA, BARNALI PAUL
Department of Microbiology Sikkim Manipal Institute of Medical Sciences 5th mile, Tadong,
Gangtok, Sikkim-737102. India
Abstract : Methicillin Resistant Staphylococcus Aureus (MRSA) strains emerged in the last decade as one of the most important nosocomial
pathogens. MRSA may invade the blood and cause potentially serious complications such as bacteremia, septic shock, and metastatic
infections. MRSA infections have recently been identified in the community. There are few studies regarding carriage state of MRSA in the
community and hence, the Epidemiology of MRSA in the community is little understood. Objectives of the study were to (1) to determine the
prevalence of staphylococcal nasal carriers among healthy adults of Gangtok, East Sikkim. (2) to determine the proportion of Methicillin
Resistant Staphylococcus species isolated from nasal carriers in healthy adults of the community. One Nasal swab from each of a total of 280
apparently healthy individuals belonging to 5 different areas of Sikkim was collected using Simple Random Sampling. The collected data
was tabulated in spreadsheets of Microsoft Excel version Office 2000 and analyzed by Epi Info version windows 2000. 247 of 280 swabs
(88.2%) out of them were found positive for staphylococcus. Among 247 staphylococcus nasal carriers, 129(52.2%) individuals were
positive for S. aureus. Staphylococcal nasal carriage among healthy adults not exposed to hospital environment was found to be high
(88.2%). It was also found that 31(24.0%) nasal swabs were positive for MRSA among those positive for S. aureus. The prevalence of MRSA
in community was thus estimated to be of 11.1%. Majority of MRSA nasal carriers in the community belonged to the age group of 20 and 40
years. Proportion of MRSA nasal carriers was lower in Ranipool (16.2%) but higher in Loomse (38.5%) than in other areas. High carriage
rates in different areas located far away from tertiary care level hospitals reveal that living close to a hospital is not a risk factor for MRSA
or MRCNS colonization. Epidemiological studies including genotyping are required to understand in detail, the dynamics of spread of
MRSA and MRCNS in the community.
Key words: Prevalence, Methicillin Resistant, Staphylococcus aureus, Nasal Carriers, Community
INTRODUCTION
Staphylococcus aureus (S. aureus), a Gram positive coccus,
is frequently found as a part of the normal human microflora.
The organism can be carried asymptomatically for weeks or
months on mucous membranes but only transiently on intact
skin1. Nasal carriers of S. aureus are more prone to skin sepsis
and postoperative staphylococcal infections than non-carriers2.
Studies show that S. aureus techoic acid, which is present in
the surface of S. aureus and coagulase negative staphylococci,
is the primary factor necessary for attachment to nasal
vestibular mucosa3. S. aureus was the most common cause of
nosocomial infections reported in USA during 1990-19964.
Methicillin Resistant Staphylococcus Aureus (MRSA) strains
were initially described in 1961 and emerged in the last decade
as one of the most important nosocomial pathogens5. MRSA
may invade the blood and cause potentially serious
complications such as bacteremia, septic shock, and serious
metastatic infections (endocarditis, pneumonia, osteomyelitis,
and arthritis) 6. Healthcare workers’ hands, the environment,
and airborne transmission (in the case of staphylococcal
pneumonia) are the most common means of spreading MRSA.
Infected and colonized patients provide the primary reservoir
and transmission is mainly through hospital staff 7. Common
factors associated with acquiring MRSA in any acute care
setting include prolonged hospital stay, use of broad spectrum
antibiotics, greater number and longer duration of antibiotic
use, stay in an ICU or burn unit, surgical wounds, decubitus
ulcers, poor functional status and proximity to another patient
with MRSA 8, 9. MRSA is a strain of S. aureus that has
developed resistance to methicillin and other beta ß-lactamaseresistant
penicillins and cephalosporins10. However, MRSA
infections have recently been identified in the community,
which raised a question of whether these infections were
transmitted from hospital, or they were caused by different
resistant strains. The sharp increase in the prevalence of MRSA
acquired infections in many communities had led to the
consideration of outpatients as a source of infection in an
institution11. However, there are few studies regarding carriage
state of MRSA in the community. Majority of the studies, so
far, had been conducted on the patients and staff members of
the hospital6. Epidemiology of MRSA in the community is
little understood or not studied at length. A few reports on
MRSA in the healthy population of Nigeria, USA, Canada,
Pakistan and Japan are available in the world literature. Till
the beginning of study no report on the prevalence of MRSA
in the community in India was available. Case reports of
community acquired MRSA infections had been increasing
since last 3 years in the tertiary care level hospitals in Gangtok
of East Sikkim. Hence, there was an urgent need for evaluation
of nasal carriage of staphylococci and Methicillin resistant
staphylococci. With this background, a study was undertaken
to determine the prevalence of MRSA among healthy subjects
Correspondence: Dr. Ankur Barua, Assistant Professor, Department of Community Medicine, Sikkim – Manipal Institute of Medical
Sciences (SMIMS), 5th Mile Tadong, Gangtok – 737 102 India Fax.: 03592-231496, e-mail : ankurbarua26@yahoo.com
192 JIMSA October-December 2008 Vol. 21 No. 4
in the community in Gangtok of East Sikkim in India.
MATERIALS & METHODS
Background Information: Gangtok with Geographic-locations
of (Lat/Lon Bounding Box: North=27.333332
South=27.333332 East=88.61667 West=88.61667 and altitude
of 1547 m) has a population of 550,000. There are two tertiary
care level hospitals, one government and the other private, at
a distance of 5 miles apart in East Sikkim.
Study Period: Two months (March 2005 - April 2005).
Sample Size: One Nasal swab from each of a total of 280
apparently healthy individuals was collected for the study.
Sampling Technique: Simple Random Sampling by using the
probability proportionate to sample size (PPS) method was
used.
Selection Method: At the beginning, a spot-map of dwellings
of different areas of East Sikkim was prepared. Then each
village and nodal areas were identified in it and numbered
serially. From these numbers, five spots (areas) in the map
were randomly selected through lottery method. Thus, the areas
selected for survey were - Deorali-Daragaon, Metro-point,
Sarswati temple area, Loomse & Ranipool in East Sikkim.
Households in the selected survey areas were numbered serially
and specific number of households in each area (as calculated
by power analysis from software package of epi-info version
windows 2000) was chosen according to PPS method.
Individual households were selected by using the random
number table. Only one individual from each household was
selected for the study through lottery method.
Study Area: Five areas that include Deorali-Daragaon, Metropoint,
Sarswati temple area, Loomse & Ranipool.
Inclusion Criteria: Only one individual was included in the
study from each household. Selection was done through lottery
method after arranging all household members in ascending
order of age.
Exclusion Criteria: Since, Staphylococcus aureus (S. aureus)
was frequently found as a part of the normal human micro
flora, children below 13 years of age were excluded from the
study. Persons who had been admitted in a hospital in the
preceding 12 months or had used any antibiotic during that
period or worked in a health care center were also not included
in this study.
Materials used for the survey: Sterile cotton-swabs, sterile
test tubes, nutrient agar (HiMedia Laboratories Private Ltd.),
Mueller-Hinton agar (HiMedia Laboratories Private Ltd.)
supplemented with 4% NaCl, Oxacillin disk-1ìg (HiMedia
Laboratories Private Ltd.), Control strain NCTC 6571 (ICMR,
Dibrugarh), Other reagents for catalase, oxidase, Coagulase,
phosphates, DNAse and sugar fermentation tests.
Data collection procedure: Nasal swabs were collected by
sterile, dry cotton swabs from anterior nares of each nostril of
a subject, inserting the swab and then gently rotating the swab
three times12. The swabs were immediately placed in test tubes
for further processing in the laboratory. All the isolates were
tested for coagulase production following standard procedures.
Staphylococci spp isolated were tested for Methicillin
resistance by using modified Stokes same plate comparative
disc diffusion method23 using 1ìg Oxacillin disk. Mueller-
Hinton agar with 4% NaCl medium was used to detect
Oxacillin resistance, incubated at 35°C for 24 hours13. Zone
diameter of the test strain was measured in millimeter with a
scale. Strains were classified as resistant or sensitive following
standard procedure.
Data Analysis: The collected data was tabulated in
spreadsheets of Microsoft Excel version Office 2000 and
analyzed by Epi Info version windows 2000.
RESULTS
Nasal swabs from 280 healthy adult subjects were examined
and among them 247(88.2%) were found to be positive for
staphylococcus. Of 247 Staphylococcal nasal carriers,
129(52.2%) were positive for Staphylococcus aureus (nasal
carriers of S. aureus) and the remaining coagulase negative
staphylococci. Out of 129 S. aureus isolates, 31(24%) isolates
were Oxacillin resistant and these are referred as MRSA. The
prevalence of MRSA in community was thus estimated to be
of 11.1%.
Among 247 staphylococcus nasal carriers, 171(69.2%) were
males and 76(30.8%) were females. S. aureus, isolated from
19(21.6%) out of 88 male, and 12(29.3%) from the 41 female
carriers were Methicillin resistant. However, difference in
carriage rates of MRSA among male and female subjects was
statistically not significant [÷2 =1.79, p=0.181(Yates
corrected)].
MRSA nasal carriers in the community were high (26.6%) in
age group of (20-40) years of age and less (10%) in age groups
below 20 years and above 40years. MRSA nasal carriage was
lower in Ranipool (16.2%) and higher in Loomse (38.5%)
than in other areas. But these differences are statistically not
significant [÷2 =1.72, p=0.156 (Fisher exact 2-tailed)].
Out of 247 staphylococcal isolates, 118 (48%) were Coagulase
Negative Staphylococci (nasal carriers of CNS) and among
them, 26(22%) CNS was found to be resistant to oxacillin,
referred to as Methicillin Resistant Coagulase Negative
Staphylococci (MRCNS). Sex-wise break up of nasal carriers
of CNS and MRCNS did not show any significant difference
[÷2=0.04, p= 0.835 (Yates corrected)] in the rates of nasal
carriage among male and female carriers. MRCNS prevalence
was high near the Saraswati temple area (28.6%) of lower
Tadong and Loomse (28.6%). MRCNS nasal carriage rate was
also higher in the age group below 40 years of age (24.75%).
DISCUSSION
S. aureus nasal carriage rates in various populations have been
investigated in the developed countries with temperate
climate14 but no such study among healthy population had been
reported from India so far. Researchers reported that nasal
carriage of S. aureus varied in different communities. The
JIMSA October-December 2008 Vol. 21 No. 4 193
results of the present study showed that nasal carriage of
staphylococci was as high as 88.2% and in 52.2% cases, S.
aureus were isolated. The prevalence of MRSA in the
apparently healthy community of East Sikkim was estimated
to be of 11.1%. A total of 129(46.1%) among 280 healthy
individuals screened were nasal carriers of Saureus. Similar
findings were reported by Anwar et al in their study in Lahore,
Pakistan who screened 1024 and 636 apparently healthy
persons from urban and rural area respectively for nasal
carriage of Staphylococcus aureus and MRSA and reported
that in urban areas prevalence of nasal carriers of S. aureus
was estimated to be 16.99%, but in rural areas, it was 11.32%.
In urban areas prevalence of nasal carriers of MRSA was found
to be 22.98% as against 11.11% in rural areas11. In a study by
Lamikanra et al it was observed that 56.4% of healthy Nigerian
students were nasal carriers of S. aureus14. Tanaka et al, while
studying S. aureus in healthy individuals in Japan reported
24.3% of them to be of nasal carriers15. In a study conducted
at University of Texas, F. Moreno et al reported that 99 (58%)
of 170 isolates of S. aureus were from community cases; the
community to nosocomial case ratio was 2:1; no significant
risk factors differentiated patients with community MRSA
from community MSSA16.
There was no statistically significant difference in the
prevalence of S. aureus nasal carriage between male and female
subjects in the present study. This finding was contrary to that
observed in the study done in Nigerian population where
females harbored S. aureus significantly more often than
males14.
An area-wise analysis of methicillin sensitive vs. resistant
strains of CNS infections showed that statistically there was
no significant difference in nasal carriage rate of MRCNS in
areas near a tertiary care level hospital and away from the
hospital. The reason for much higher rate of MRSA nasal
carriage in Gangtok needs to be further investigated. A
surveillance centre is necessary to be established for
monitoring the problem of MRSA and MRCNS among the
general population in India since Methicillin Resistant strains
are increasing in other parts of the world. It is clear that
epidemiological studies including genotyping are required to
understand in detail, the dynamics of spread of MRSA and
MRCNS in the community. Moreover, acute and recurrent
infections with S. aureus and MARSA are a possibility of
developing drug resistant staphylococcal strains in the
community. As the threat of acquiring multi-drug resistant
staphylococcal infection increases with increasing prevalence
of MRSA in general population, it is recommended that more
studies be carried out in a larger scale in the general population
along with the hospitals in order to keep updated information
on nasal carriage of MRSA.
CONCLUSION
Case reports of community acquired MRSA infections had
been increasing since last 3 years in the tertiary care level
hospitals in Gangtok of East Sikkim. Hence, there was an
urgent need for evaluation of nasal carriage of staphylococci
and Methicillin resistant staphylococci. The prevalence of
MRSA in the apparently healthy community of East Sikkim
was estimated to be of 11.1%. Majority of MRSA nasal carriers
in the community belonged to the age group of 20 and 40 years.
Proportion of MRSA nasal carriers was lower in Ranipool
(16.2%) but higher in Loomse (38.5%) than in other areas.
Staphylococcal nasal carriage among healthy adults, not
exposed to hospital environment, was found to be high (88.2%).
It was found in this study that there was no age / gender /
location specific difference in nasal carriage rate of MRSA or
MRCNS around the tertiary care level hospitals. High rate of
MRSA nasal carriage among healthy adults in general
population needed further investigation. High carriage rates
in different areas located far away from tertiary care level
hospitals reveal that living close to a hospital is not a risk factor
for MRSA or MRCNS colonization. Epidemiological studies
including genotyping are required to understand in detail, the
dynamics of spread of MRSA and MRCNS in the community.
REFERENCES
1 Archer GL. Staphylococcus aureus: a well armed pathogen. Clin Infect Dis 1998; 26:
1179-81.
2 Casewell MW. The nose-an underestimated source of Staphylococcus aureus causing
wound infection. J Hosp Infect 1998; 40 (suppl B): S3-11.
3 Weidenmaier C, Kokai-Kun JF, Kristian SA, Shanturiya T, Kalbacher H, Gross M, et
al. Role of techoic acid in Staphylococcus aureus nasal colonization, a major risk factor
in nosocomial infection. Nat. Med. 2004; 10: 243-245.
4 Centers for Disease Control and Prevention. National Nosocomial Infections Surveillance
system report: data from 1986-1996. Atlanta (GA); 1996.
5 Maple PAC, Hamilton – Miller JMT, Brumfit W. Worldwide Antibiotic Resistance in
Methicillin Resistant Staphylococcus aureus. Lancet 1989; 1:537-540.
6 Locksley RM. Staphylococcal infections. In: Wilson JD et al., editors. Harrison’s Principles
of Internal Medicine 12th edition, USA: MacGraw-Hill Inc.; 1995. P557-62.
7 McDonald M. The Epidemiology of Methicillin Resistant Staphylococcus aureus: Surgical
Relevance 20 years on. Aust. NZJ Surg 1997; 67: 682-685.
8 Boyce JM. Et al. MRSA: a briefing for acute care hospitals and nursing facilities.
Infection Control Hospital Epidemiology. 1994; 15:105-15.
9 Doebbeling BN. The Epidemiology of Methicillin Resistant Staphylococcus aureus colonization
and infection. J. Chemotherapeutics 1995; 7(Suppl.3): 99-103.
10 Chambers HF. Methicillin resistance in Staphylococci: genetics and mechanisms of
resistance. Clinical Microbiology Rev. 1997; 10: 781-91.
11 Anwar MS, Ghazala J, Bhatti KR, Tayyib M, Bokhari SR. Assesment of Staphylococcus
aureus and MRSA nasal carriage in general population. JCPSP 2004, vol 14 (11):
661-664.
12 Paterson David L, Rihs John D, Squier Cheryl, Gayowski Timothy, Sagnimeni Asia,
Singh Nina: Lack of efficacy of mupirocin in the prevention of infections with staphylococcus
aureus in liver transplant recipients and candidates. Transplantation. 2003;
75(2):194-198.
13 McDougal LK, Thornsberry C: New recommendations for disk diffusion antimicrobial
susceptibility tests for methicillin-resistant (heteroresistant) staphylococci. J Clin
Microbiol. 1984; 19:482-488.
14 Lamikanra A, Paul BD, Akinwole OB, Paul MO. Nasal carriage of Staphlococcus
aureus in a population of healthy Nigerian students. J Med Microbiol 1985; 19: 211-
216.
15 Tanaka Y, Okada H, Adachi A. Nasal Carriage of Staphylococcus aureus among healthy
individuals. Journal of Japanese Association of Infectious Disesaes. 1993; 67: 987-
991.
16 Moreno F, Crisp C, Jorgensen JH, Patterson JE. Methicillin-resistant Staphylococcus
aureus as a community organism. Clin Infect Dis. 1996;23(4):851-2.
ORIGINAL
PREVALENCE OF NASAL CARRIAGE OF METHICILLIN RESISTANT
STAPHYLOCOCCI IN HEALTHY POPULATION OF GANGTOK,
EAST SIKKIM
DEVJYOTI MAJUMDAR, ANKUR BARUA, BARNALI PAUL
Department of Microbiology Sikkim Manipal Institute of Medical Sciences 5th mile, Tadong,
Gangtok, Sikkim-737102. India
Abstract : Methicillin Resistant Staphylococcus Aureus (MRSA) strains emerged in the last decade as one of the most important nosocomial
pathogens. MRSA may invade the blood and cause potentially serious complications such as bacteremia, septic shock, and metastatic
infections. MRSA infections have recently been identified in the community. There are few studies regarding carriage state of MRSA in the
community and hence, the Epidemiology of MRSA in the community is little understood. Objectives of the study were to (1) to determine the
prevalence of staphylococcal nasal carriers among healthy adults of Gangtok, East Sikkim. (2) to determine the proportion of Methicillin
Resistant Staphylococcus species isolated from nasal carriers in healthy adults of the community. One Nasal swab from each of a total of 280
apparently healthy individuals belonging to 5 different areas of Sikkim was collected using Simple Random Sampling. The collected data
was tabulated in spreadsheets of Microsoft Excel version Office 2000 and analyzed by Epi Info version windows 2000. 247 of 280 swabs
(88.2%) out of them were found positive for staphylococcus. Among 247 staphylococcus nasal carriers, 129(52.2%) individuals were
positive for S. aureus. Staphylococcal nasal carriage among healthy adults not exposed to hospital environment was found to be high
(88.2%). It was also found that 31(24.0%) nasal swabs were positive for MRSA among those positive for S. aureus. The prevalence of MRSA
in community was thus estimated to be of 11.1%. Majority of MRSA nasal carriers in the community belonged to the age group of 20 and 40
years. Proportion of MRSA nasal carriers was lower in Ranipool (16.2%) but higher in Loomse (38.5%) than in other areas. High carriage
rates in different areas located far away from tertiary care level hospitals reveal that living close to a hospital is not a risk factor for MRSA
or MRCNS colonization. Epidemiological studies including genotyping are required to understand in detail, the dynamics of spread of
MRSA and MRCNS in the community.
Key words: Prevalence, Methicillin Resistant, Staphylococcus aureus, Nasal Carriers, Community
INTRODUCTION
Staphylococcus aureus (S. aureus), a Gram positive coccus,
is frequently found as a part of the normal human microflora.
The organism can be carried asymptomatically for weeks or
months on mucous membranes but only transiently on intact
skin1. Nasal carriers of S. aureus are more prone to skin sepsis
and postoperative staphylococcal infections than non-carriers2.
Studies show that S. aureus techoic acid, which is present in
the surface of S. aureus and coagulase negative staphylococci,
is the primary factor necessary for attachment to nasal
vestibular mucosa3. S. aureus was the most common cause of
nosocomial infections reported in USA during 1990-19964.
Methicillin Resistant Staphylococcus Aureus (MRSA) strains
were initially described in 1961 and emerged in the last decade
as one of the most important nosocomial pathogens5. MRSA
may invade the blood and cause potentially serious
complications such as bacteremia, septic shock, and serious
metastatic infections (endocarditis, pneumonia, osteomyelitis,
and arthritis) 6. Healthcare workers’ hands, the environment,
and airborne transmission (in the case of staphylococcal
pneumonia) are the most common means of spreading MRSA.
Infected and colonized patients provide the primary reservoir
and transmission is mainly through hospital staff 7. Common
factors associated with acquiring MRSA in any acute care
setting include prolonged hospital stay, use of broad spectrum
antibiotics, greater number and longer duration of antibiotic
use, stay in an ICU or burn unit, surgical wounds, decubitus
ulcers, poor functional status and proximity to another patient
with MRSA 8, 9. MRSA is a strain of S. aureus that has
developed resistance to methicillin and other beta ß-lactamaseresistant
penicillins and cephalosporins10. However, MRSA
infections have recently been identified in the community,
which raised a question of whether these infections were
transmitted from hospital, or they were caused by different
resistant strains. The sharp increase in the prevalence of MRSA
acquired infections in many communities had led to the
consideration of outpatients as a source of infection in an
institution11. However, there are few studies regarding carriage
state of MRSA in the community. Majority of the studies, so
far, had been conducted on the patients and staff members of
the hospital6. Epidemiology of MRSA in the community is
little understood or not studied at length. A few reports on
MRSA in the healthy population of Nigeria, USA, Canada,
Pakistan and Japan are available in the world literature. Till
the beginning of study no report on the prevalence of MRSA
in the community in India was available. Case reports of
community acquired MRSA infections had been increasing
since last 3 years in the tertiary care level hospitals in Gangtok
of East Sikkim. Hence, there was an urgent need for evaluation
of nasal carriage of staphylococci and Methicillin resistant
staphylococci. With this background, a study was undertaken
to determine the prevalence of MRSA among healthy subjects
Correspondence: Dr. Ankur Barua, Assistant Professor, Department of Community Medicine, Sikkim – Manipal Institute of Medical
Sciences (SMIMS), 5th Mile Tadong, Gangtok – 737 102 India Fax.: 03592-231496, e-mail : ankurbarua26@yahoo.com
192 JIMSA October-December 2008 Vol. 21 No. 4
in the community in Gangtok of East Sikkim in India.
MATERIALS & METHODS
Background Information: Gangtok with Geographic-locations
of (Lat/Lon Bounding Box: North=27.333332
South=27.333332 East=88.61667 West=88.61667 and altitude
of 1547 m) has a population of 550,000. There are two tertiary
care level hospitals, one government and the other private, at
a distance of 5 miles apart in East Sikkim.
Study Period: Two months (March 2005 - April 2005).
Sample Size: One Nasal swab from each of a total of 280
apparently healthy individuals was collected for the study.
Sampling Technique: Simple Random Sampling by using the
probability proportionate to sample size (PPS) method was
used.
Selection Method: At the beginning, a spot-map of dwellings
of different areas of East Sikkim was prepared. Then each
village and nodal areas were identified in it and numbered
serially. From these numbers, five spots (areas) in the map
were randomly selected through lottery method. Thus, the areas
selected for survey were - Deorali-Daragaon, Metro-point,
Sarswati temple area, Loomse & Ranipool in East Sikkim.
Households in the selected survey areas were numbered serially
and specific number of households in each area (as calculated
by power analysis from software package of epi-info version
windows 2000) was chosen according to PPS method.
Individual households were selected by using the random
number table. Only one individual from each household was
selected for the study through lottery method.
Study Area: Five areas that include Deorali-Daragaon, Metropoint,
Sarswati temple area, Loomse & Ranipool.
Inclusion Criteria: Only one individual was included in the
study from each household. Selection was done through lottery
method after arranging all household members in ascending
order of age.
Exclusion Criteria: Since, Staphylococcus aureus (S. aureus)
was frequently found as a part of the normal human micro
flora, children below 13 years of age were excluded from the
study. Persons who had been admitted in a hospital in the
preceding 12 months or had used any antibiotic during that
period or worked in a health care center were also not included
in this study.
Materials used for the survey: Sterile cotton-swabs, sterile
test tubes, nutrient agar (HiMedia Laboratories Private Ltd.),
Mueller-Hinton agar (HiMedia Laboratories Private Ltd.)
supplemented with 4% NaCl, Oxacillin disk-1ìg (HiMedia
Laboratories Private Ltd.), Control strain NCTC 6571 (ICMR,
Dibrugarh), Other reagents for catalase, oxidase, Coagulase,
phosphates, DNAse and sugar fermentation tests.
Data collection procedure: Nasal swabs were collected by
sterile, dry cotton swabs from anterior nares of each nostril of
a subject, inserting the swab and then gently rotating the swab
three times12. The swabs were immediately placed in test tubes
for further processing in the laboratory. All the isolates were
tested for coagulase production following standard procedures.
Staphylococci spp isolated were tested for Methicillin
resistance by using modified Stokes same plate comparative
disc diffusion method23 using 1ìg Oxacillin disk. Mueller-
Hinton agar with 4% NaCl medium was used to detect
Oxacillin resistance, incubated at 35°C for 24 hours13. Zone
diameter of the test strain was measured in millimeter with a
scale. Strains were classified as resistant or sensitive following
standard procedure.
Data Analysis: The collected data was tabulated in
spreadsheets of Microsoft Excel version Office 2000 and
analyzed by Epi Info version windows 2000.
RESULTS
Nasal swabs from 280 healthy adult subjects were examined
and among them 247(88.2%) were found to be positive for
staphylococcus. Of 247 Staphylococcal nasal carriers,
129(52.2%) were positive for Staphylococcus aureus (nasal
carriers of S. aureus) and the remaining coagulase negative
staphylococci. Out of 129 S. aureus isolates, 31(24%) isolates
were Oxacillin resistant and these are referred as MRSA. The
prevalence of MRSA in community was thus estimated to be
of 11.1%.
Among 247 staphylococcus nasal carriers, 171(69.2%) were
males and 76(30.8%) were females. S. aureus, isolated from
19(21.6%) out of 88 male, and 12(29.3%) from the 41 female
carriers were Methicillin resistant. However, difference in
carriage rates of MRSA among male and female subjects was
statistically not significant [÷2 =1.79, p=0.181(Yates
corrected)].
MRSA nasal carriers in the community were high (26.6%) in
age group of (20-40) years of age and less (10%) in age groups
below 20 years and above 40years. MRSA nasal carriage was
lower in Ranipool (16.2%) and higher in Loomse (38.5%)
than in other areas. But these differences are statistically not
significant [÷2 =1.72, p=0.156 (Fisher exact 2-tailed)].
Out of 247 staphylococcal isolates, 118 (48%) were Coagulase
Negative Staphylococci (nasal carriers of CNS) and among
them, 26(22%) CNS was found to be resistant to oxacillin,
referred to as Methicillin Resistant Coagulase Negative
Staphylococci (MRCNS). Sex-wise break up of nasal carriers
of CNS and MRCNS did not show any significant difference
[÷2=0.04, p= 0.835 (Yates corrected)] in the rates of nasal
carriage among male and female carriers. MRCNS prevalence
was high near the Saraswati temple area (28.6%) of lower
Tadong and Loomse (28.6%). MRCNS nasal carriage rate was
also higher in the age group below 40 years of age (24.75%).
DISCUSSION
S. aureus nasal carriage rates in various populations have been
investigated in the developed countries with temperate
climate14 but no such study among healthy population had been
reported from India so far. Researchers reported that nasal
carriage of S. aureus varied in different communities. The
JIMSA October-December 2008 Vol. 21 No. 4 193
results of the present study showed that nasal carriage of
staphylococci was as high as 88.2% and in 52.2% cases, S.
aureus were isolated. The prevalence of MRSA in the
apparently healthy community of East Sikkim was estimated
to be of 11.1%. A total of 129(46.1%) among 280 healthy
individuals screened were nasal carriers of Saureus. Similar
findings were reported by Anwar et al in their study in Lahore,
Pakistan who screened 1024 and 636 apparently healthy
persons from urban and rural area respectively for nasal
carriage of Staphylococcus aureus and MRSA and reported
that in urban areas prevalence of nasal carriers of S. aureus
was estimated to be 16.99%, but in rural areas, it was 11.32%.
In urban areas prevalence of nasal carriers of MRSA was found
to be 22.98% as against 11.11% in rural areas11. In a study by
Lamikanra et al it was observed that 56.4% of healthy Nigerian
students were nasal carriers of S. aureus14. Tanaka et al, while
studying S. aureus in healthy individuals in Japan reported
24.3% of them to be of nasal carriers15. In a study conducted
at University of Texas, F. Moreno et al reported that 99 (58%)
of 170 isolates of S. aureus were from community cases; the
community to nosocomial case ratio was 2:1; no significant
risk factors differentiated patients with community MRSA
from community MSSA16.
There was no statistically significant difference in the
prevalence of S. aureus nasal carriage between male and female
subjects in the present study. This finding was contrary to that
observed in the study done in Nigerian population where
females harbored S. aureus significantly more often than
males14.
An area-wise analysis of methicillin sensitive vs. resistant
strains of CNS infections showed that statistically there was
no significant difference in nasal carriage rate of MRCNS in
areas near a tertiary care level hospital and away from the
hospital. The reason for much higher rate of MRSA nasal
carriage in Gangtok needs to be further investigated. A
surveillance centre is necessary to be established for
monitoring the problem of MRSA and MRCNS among the
general population in India since Methicillin Resistant strains
are increasing in other parts of the world. It is clear that
epidemiological studies including genotyping are required to
understand in detail, the dynamics of spread of MRSA and
MRCNS in the community. Moreover, acute and recurrent
infections with S. aureus and MARSA are a possibility of
developing drug resistant staphylococcal strains in the
community. As the threat of acquiring multi-drug resistant
staphylococcal infection increases with increasing prevalence
of MRSA in general population, it is recommended that more
studies be carried out in a larger scale in the general population
along with the hospitals in order to keep updated information
on nasal carriage of MRSA.
CONCLUSION
Case reports of community acquired MRSA infections had
been increasing since last 3 years in the tertiary care level
hospitals in Gangtok of East Sikkim. Hence, there was an
urgent need for evaluation of nasal carriage of staphylococci
and Methicillin resistant staphylococci. The prevalence of
MRSA in the apparently healthy community of East Sikkim
was estimated to be of 11.1%. Majority of MRSA nasal carriers
in the community belonged to the age group of 20 and 40 years.
Proportion of MRSA nasal carriers was lower in Ranipool
(16.2%) but higher in Loomse (38.5%) than in other areas.
Staphylococcal nasal carriage among healthy adults, not
exposed to hospital environment, was found to be high (88.2%).
It was found in this study that there was no age / gender /
location specific difference in nasal carriage rate of MRSA or
MRCNS around the tertiary care level hospitals. High rate of
MRSA nasal carriage among healthy adults in general
population needed further investigation. High carriage rates
in different areas located far away from tertiary care level
hospitals reveal that living close to a hospital is not a risk factor
for MRSA or MRCNS colonization. Epidemiological studies
including genotyping are required to understand in detail, the
dynamics of spread of MRSA and MRCNS in the community.
REFERENCES
1 Archer GL. Staphylococcus aureus: a well armed pathogen. Clin Infect Dis 1998; 26:
1179-81.
2 Casewell MW. The nose-an underestimated source of Staphylococcus aureus causing
wound infection. J Hosp Infect 1998; 40 (suppl B): S3-11.
3 Weidenmaier C, Kokai-Kun JF, Kristian SA, Shanturiya T, Kalbacher H, Gross M, et
al. Role of techoic acid in Staphylococcus aureus nasal colonization, a major risk factor
in nosocomial infection. Nat. Med. 2004; 10: 243-245.
4 Centers for Disease Control and Prevention. National Nosocomial Infections Surveillance
system report: data from 1986-1996. Atlanta (GA); 1996.
5 Maple PAC, Hamilton – Miller JMT, Brumfit W. Worldwide Antibiotic Resistance in
Methicillin Resistant Staphylococcus aureus. Lancet 1989; 1:537-540.
6 Locksley RM. Staphylococcal infections. In: Wilson JD et al., editors. Harrison’s Principles
of Internal Medicine 12th edition, USA: MacGraw-Hill Inc.; 1995. P557-62.
7 McDonald M. The Epidemiology of Methicillin Resistant Staphylococcus aureus: Surgical
Relevance 20 years on. Aust. NZJ Surg 1997; 67: 682-685.
8 Boyce JM. Et al. MRSA: a briefing for acute care hospitals and nursing facilities.
Infection Control Hospital Epidemiology. 1994; 15:105-15.
9 Doebbeling BN. The Epidemiology of Methicillin Resistant Staphylococcus aureus colonization
and infection. J. Chemotherapeutics 1995; 7(Suppl.3): 99-103.
10 Chambers HF. Methicillin resistance in Staphylococci: genetics and mechanisms of
resistance. Clinical Microbiology Rev. 1997; 10: 781-91.
11 Anwar MS, Ghazala J, Bhatti KR, Tayyib M, Bokhari SR. Assesment of Staphylococcus
aureus and MRSA nasal carriage in general population. JCPSP 2004, vol 14 (11):
661-664.
12 Paterson David L, Rihs John D, Squier Cheryl, Gayowski Timothy, Sagnimeni Asia,
Singh Nina: Lack of efficacy of mupirocin in the prevention of infections with staphylococcus
aureus in liver transplant recipients and candidates. Transplantation. 2003;
75(2):194-198.
13 McDougal LK, Thornsberry C: New recommendations for disk diffusion antimicrobial
susceptibility tests for methicillin-resistant (heteroresistant) staphylococci. J Clin
Microbiol. 1984; 19:482-488.
14 Lamikanra A, Paul BD, Akinwole OB, Paul MO. Nasal carriage of Staphlococcus
aureus in a population of healthy Nigerian students. J Med Microbiol 1985; 19: 211-
216.
15 Tanaka Y, Okada H, Adachi A. Nasal Carriage of Staphylococcus aureus among healthy
individuals. Journal of Japanese Association of Infectious Disesaes. 1993; 67: 987-
991.
16 Moreno F, Crisp C, Jorgensen JH, Patterson JE. Methicillin-resistant Staphylococcus
aureus as a community organism. Clin Infect Dis. 1996;23(4):851-2.
DEPRESSION IN ELDERLY:A CROSS-SECTIONAL STUDY IN RURAL SOUTH INDIA
JIMSA October - December 2007 Vol. 20 No. 4 259
DEPRESSION IN ELDERLY:
A CROSS-SECTIONAL STUDY IN RURAL SOUTH INDIA
Ankur Barua, Das Acharya, K Nagaraj, H Vinod Bhat, NS Nair
Department of Community Medicine, Kasturba Medical College, Manipal, India
Abstract : The objectives of the study were to determine the prevalence of depression in elderly rural population and also study the sociodemographic
correlates of the depressive disorders among the elderly in this community. It was cross sectional study performed on the
elderly subjects of rural area of Udupi taluk Karnataka in South India over 8 months period. A total of 627 elderly individuals of age group
of 60 years and above, were interrogated : results were subjected to statistical analysis i.e proportions and their 95% confidence intervals,
Chi-square test, multiple logistic regression and its 95% confidence interval. The prevalence of depression in elderly population was
determined to be 21 .7%. The prevalence in the age group of 80 years and above and those individuals who had a history of death in the
family within the last six months were found to be 34.4% and 52.4%, respectively. Multiple logistic regression analysis revealed that these
two correlates were independently associated with depressive disorders in elderly population.
Key words: Depression, Prevalence, Correlates, Elderly, Multiple Logistic Regression
INTRODUCTION
The Indian aged population is currently the second largest in the world.
The proportion of those who would be aged 60 years and above is estimated
to be 7.7% for the year 2000, and this proportion is expected to reach
12.6% in 2025.1 A high prevalence of mental disorders is seen in old age.
Predominant among these is depression1. The future projections of global
DALY’s in the year 2020 show that mental disorders are projected to
increase to 15% of the global disease burden and unipolar major depression
could become the second leading cause disease burden after ischemic
heart disease12 especially in high-income countries. The communitybased
mental health studies have revealed that the point prevalence of
depressive disorders among the geriatric population in India varies between
13 and 25 percent According to the observations made by the World
Health Organization, the correlates -= disorders in old age are reported
as genetic susceptibility chronic disease and disability, pain,, frustration
with limitations in activities of daily living - events (widowhood, separation,
divorce, bereavement, poverty, social, isolation ) and lake of adequate
social support. Though depression is the commonest mental health
problem in old age, very few community-based studies had been conducted
in India, to understand the problem. No such study had been conducted
in the past in Udupi taluk of Karnataka. Considering this background, a
community-based mental health study was conducted in the rural area of
Udupi taluk to determine the disease burden of depressive disorders and
to study the correlates of depression among the elderly in the community.
MATERIAL AND METHODS
The rural field practice area of the Department of Community Medicine,
Kasturba Medical College, Manipal is located in the coastal area of Udupi
taluk in Udupi District of the state of Karnataka in South India. The total
geriatric population (>60yrs) in the field practice area is approximately
10.5% of the total population covered by the rural field practice area.
Study period: 8 months ( March to October 2002).
Setting: Three villages i.e.—Udayavara, Kadekar, and Katapady.
Study Design : Cross-sectional study.
The sample size was estimated for finite population with the help of EPIinfo
version 5.0 statistical package. The total geriatric population
(>=60yrs.) covered by the 3 RMCW homes was estimated to be of 2259.
Here, the confidence level was taken as 95%, 11 .2% prevalence rate of
depression, required relative precision of the estimate was set at 20% and
a non-response rate of 10% was included; hence, the final sample size
was determined as 627.
Sample size : 627 people in the age group of 60yrs and above, who were
permanent members of their respective households, were selected for the
study.
Sampling method : Simple Random Sampling ‘without replacement
method using the Probability proportionate to size (PPS) technique was
used.
Sampling Procedure - Exclusion criteria: If a designated house was
found locked during the first visit and the eligible residents could not be
contacted and even after 2 successive revisits then they were all excluded
from this study. Criteria For Defining A Non-Respondent: If a designated
respondent was non-cooperative or had severe behavioural problems or
cognitive impairment, had severe hearing impairment or articulation
disorder, had any terminal illness or if he could not be contacted during
two separate revisits after the first, then he was considered a non-respondent
Selection Procedure: Due to some on-going projects in some of the field
practice areas, only 3 centres out of the total 6 RMCW (Rural Maternity
And Child Welfare) Homes were chosen for our project As all the villages
in the field practice area are culturally and sacio-demographically identical,
this selection bias had minimal effect on the results, Using PPS (probability
proportionate to size) method, the required number of parucipants from
each village was decided. Then the households and parcipants were
randomly selected from updated family folders in RMCW homes using
the random number table. All the eligible candidates of the selected
households were interviewed as it was presumed that the effect of genetive
susceptbility would be minimal because only 4% of our study population
had either 1st degree or 2nd degree relatives residing together in the same
household.
Study Instruments: A fact sheet consisting of information regarding the
household of the respondent was used for data collection. A semi-structured
proforma containing information regarding the soclo-economic status of
the individual that was later estimated by the modified Udai Pareek Scale8
was also used, Presence of depressive disorders was determined using
the instrument Mastering Depression In Primary Care Version 2.2: It had
two components: (a) WHO (five) Well-being Index (1998 version), (b)
Major (lCD-b) Depression Inventory. Cognitive impairment was estimated
by the 6CIT Dementia Test. Mastering Depression In Primary Care Version
2.2 and the 6CIT Dementia Test were translated into Kannada and Hindi
by the researchers and back-translated into English by another expert, not
acquainted with the original versions. The back-translation was
subsequently compared with the original version by a psychiatrist for
conceptual equivalence of the items.
Organization Of Field Work And Data Collection
The investigator, along with three field ANMs (auxiliary nurse mid-wives),
Correspondence: Dr. Ankur Barua, Assistant Professor, Department
of Community Medicine Sikkim – Manipal Institute of Medical
Sciences (SMIMS) 5th Mile Tadong, Gangtok – 737 102 India
Fax.: 03592-231496, E-mail : ankurbarua26@yahoo.com
ORIGINAL
260 JIMSA October - December 2007 Vol. 20 No. 4
were trained by the psychiatrists on how to administer the questionnaires.
All our study instruments were pre-tested to determine whether they
optimally suited our field conditions. At the beginning, officials of the
local panchayat office, village leaders, Anganwadi workers and the ANMs
were contacted and their help was sought to understand the geography of
the sites and to trace the households. After informed verbal consent was
obtained, the designated respondent(s) of a particular household was
administered the selected sets of questionnaires by the investigator along
with the help of the field ANMs. Care was taken to ensure privacy and
confidentiality of the interview as part of the study. A brief general health
check-up of the respondent was conducted at the beginning to establish a
good rapport with him and also to gain his confidence. Alt the
questionnaires administered in the field were evaluated and rated on the
spot, and If a respondent became positive in any of our screening or
diagnostic instruments he was immediately handed over a referral slip
and sincerely requested to visit the psychiatry OPD of Kasturba Hospital,
Manipal at the earliest for a free consultancy. The participants having
obvious medical disorders were referred to the nearest RMCW homes
for a free health check-up. The diagnoses generated by the instruments in
our study were strictiy kept confidential and were reconfirmed by
consulting a senior faculty member of the department of psychiatry of
KMC Hospital, Manipal before arriving at a final lCD-b diagnosis for
data analysis.
Data Analysis
The collected data was tabulated and analysed by using the statistical
package SPSS (Statistical Package For Social Sciences) version 10.0 for
Windows. Findings were described in terms of proportions and their
95% confidence Intervals. chi-square test was applied to study the
relationship between different variables and depression. To determine
the independent effect of various factors on depressive disorders, multiple
logistic regression was performed and their significance was estimated in
terms of adjusted OR and its 95% confidence interval. P value less than
0.05 was considered as significant.
RESULTS AND DISCUSSION
During our field survey, 487 households were visited and 627 individuals
in the geriatric age group of 60 years and above were contacted. Among
these 627 elderly people, we could interview only 609 individuals for the
assessment of depressive disorders (97.1%), The 18 individuals, whom
we could not interview due to various reasons, were categorized as nonrespondents
(2.9%). The baseline characteristics of the population
surveyed revealed that 36.0% were males while 64.0% were females.
Majority (52.6%) belonged to the age group of (60-69) years. Only 58.7%
of the elderly were literates. Majority (61.2%) belonged to the middle
socio-economic status and 56.3% of the individuals were married.
The overall prevalence of depressive disorders among the elderly of 60
years and above was found to be 21.7% (95%Cl18.4-24.9). Our study
findings were consistent with the observations made by Nandi et a14,
West Bengal, Ramachandran V. et a15 Madras and Tiwari S.C. Lucknow,3
who had determined the prevalence of depressive disorders in the geriatric
population to be 22.0%, 24.1% and 13.5% respectively. However, a high
prevalence of depressive disorders of 52.2% among the elderly 60 years
was observed in the study conducted by Nandi et a19 in the rural areas of
West Bengal. In contrast to these observations, Rao Venkoba A. et al10
Madurai had recorded the prevalence of depression to be as low as 6.0%.
Studies conducted by Newman at Canada, and Kennedy et al6, USA
reported prevalence of depression among the elderly to be 11 .2% and
16.9%; respectively. We had also assessed the status of positive weltbeing
by using the WHO (Five) Well-Being index (version 1998). We
had observed that the prevalence of depressive disorders was high among
individuals whose status of positive well-being was poor (75.9%) as
compared to those who were satisfactory (5.3%). Table 1 Shows the
prevalence of depressive disorders according to various sociodemographic
correlates.
In this study, the prevalence of depressive disorders was higher among
females (22.6%) than males (19.9%), but this difference was not found to
be statistically significant (x2= 0.616, dt=1, p= 0.433). Our study findings
are consistent with the study by Blazer 12 (1979, North Carolina), where
the prevalence of depression was similar in both sexes. However, the
studies conducted by previous workers 5,6,11,13 had documented a high
prevalence of depression among the elderly females. Higher standards of
living, matriarchal family system and a high female literacy rate (94.6%)
could explain a lower prevalence of depression among females in our
study.
The age of the respondents ranged between 60to93 years, while the
mean age was found to be 69.0 years (SD6.8). The revalence of depressive
disorders was highest (34.4%) in the age group of 80 years and above.
The difference in prevalence of depression between different age groups
was found to be statistically significant (x2 9.932, df2, p0.007). The
prevalence of depressive disorders showed a positive linear trend of
increase with the progression of age, which was also found to be statistically
significant. Majority otud’pop were Hindus (80.1%). The prevalence of
depressive disorders did not vary widely among the Hindus (22.5%),
Christians (17.3%) and Muslims (20.0%) and the difference was not
found to be statistically significant. Similar findings were reported from a
study conducted by Tiwari3. The prevalence of depressive disorders was
high among the individuals belonging to the low economic status (SES)
group (25.2%) and high socia economic status (13.6%) groups. But the
difference between these groups was not found to be statiscally significant.
Studies conducted by several worker 5,6,13 had observed the prevelance of
depressive disorders to be significantly higher among the elderly belonging
to the low SES group.The prevalence of depressive disorders was similar
among the unmarried widowed or separated individuals (23.2%) as
compared to their married counterparts (20.5%). Our study findings were
not consistent with the previous studies 56 who had documented a
significantly high prevalence of depressive disorders among the widowed
individuals, in this study, we had observed that majority of the unmarried,
widowed or separated individuals were women (92.1%) with only a few
staying alone (5.6%) and deprived of any living child (5.2%). Better
JIMSA October - December 2007 Vol. 20 No. 4 261
standards of living, a satisfactory level of family support systems network,
high female literacy rate (94.6%) and matriarchal family system could
explain a lower prevalence of depression among these individuals in our
study.
In this study we found that the prevalence of depressive disorders remained
similar in case of both nuclear (20.6%) and print/extended families (22.2%).
The respondents, staying alone 16 (2.6%), were not included under nuclear
family. - ln this study, only 16 (2.6%) of the individuals were living alone.
The prevalence of depression among those who were staying alone, living
only with their children or relatives or living with their spouse was found
to be 18.8%, 22.9% and 20.8% respectively. But the difference between
these groups was not found to be statistically significant These findings
were in contrast with the studies conducted by Ramachandran5.
Blazer Dan12 and Kennedy Gary J.6 who had observed a significantly
high prevalence of depression among those living alone.
The prevalence of depressive disorders among illiterates was higher (254%)
as compared to literates (19.0%). The difference between the two groups
was however, not found to be statistically significant. Ramachandran V.15
‘Madrasad also reported similar observations. Studies conducted by
Kennedy et al16 and Penninx et al also reported a significantly higher
prevalence of depression among individuals with lower level of education.
None of the respondents were unemployed in the past. The proportion of
housewives affected with depressive disorders was 20.1%. The prevalence
of depressive disorders was almost similar among the unskilled (23.1%)
and skilled (24.5) labourers. Some of the previous 5,6 had reported a higher
prevalence of depression among the unemployed individuals.
As compared to smoking and alcohol consumption (17.2%), tobacco
chewing (39.2%) and pan chewing (49.9%) habits were common among
the geriatric population in Udupi Taluk. In this study, the prevalence of
depression was found to be significantly high among the having pan
chewing individuals (25.7%), tobacco chewing (26.1%) and alcohol
consumption (29.1%) habits. In a study conducted by Hämäläinen J. et
al14 from Finland, it was found that cigarette smoking and alcohol
consumption were important risk factors for major depressive episode.
The prevalence of depression was similar among those who gave a history
of psychiatric illness (19.5%) as compared to those without family history
of psychiatric illness (21.8%) and the difference between the groups was
not found to be statistically significant. These findings are in contrast with
the observations by Ojen Van15 who reported a significantly high prevalence
of depression among those with a positive family history of mental
disorders. This difference from our study might be due to social stigma
resulting in considerable number of under-reported and undiagnosed cases
of mental illness.
The prevalence of depression was high among the individuals who had a
history of death in their family within the last 6 months. The difference
between the two groups was found to be statistically significant . Similar
observations were also noted by Kennedy Gary6.
Table 2 describes the association between correlates of depressive disorders
according to the univariate as well as the multivariate analysis.
It was observed by univariate analysis age group of 80 years and above
and a history of death in the family within last 6 months had strong and
significant association with depressive disorders. However, Multiple
Logistic Regression analysis revealed that age group of eighty years and
above and a history of death in the family within last six months had
independent significant association with depressive disorders in the
geriatric population. These findings are consistent with the observations
from the study conducted by Kennedy Gary6.
CONCLUSIONS
In this study, the prevalence of depressive disorders among the geriatric
population was determined to be 21.7%. The prevalence rates of depression
among the males and females were 19.9% and 22.6%, respectively.
Multiple logistic regression analysis revealed that age group of 80 years
and above and a history of death in the family within the last six months
were indepenc1eny associated with depressive disorders in the geriatric
population.
LIMITATIONS
Due to feasibility constraints, we could not interview the people who
lived in the open and were homeless. Due to the lack of practical skills in
communication, we could not interview the non-respondents who were
having severe hearing impairment and aphasia. Since the proportion of
non-respondents and the individuals who were homeless was very small
in our study population, we expect only a minimal effect on our prevalence
estimate.
ACKNOWLEDGEMENTS
The authors would like to express their deep sense of gratitude to Dr. R.S.
Phaneendra Rao, Dean, Professor of Community Medicine, Kasturba
Medical College, Manipal for his invaluable support, critical evaluation
and skilled guidance throughout the study. The authors are also indebted
to Dr. N. Kar, Associate Professor, Department of Psychiatry, Kasturba
Medical College, Manipal for his technical guidance and valuable advice
on various aspects of psychiatric evaluation.
REFERENCES
1. The World Health Organization. World Health Report Mental Health: New understanding
New Hope. Geneva: The institute; 2001
2. Wig NN. World Health Day, 2001. Indian Journal of Psychiatry 2001; 43(1): 1-4.
3. Tiwari SC. Gerfa —Naffic morbidfty in ru:a riocthern India: implications for tne futjre
International Psychogenatrics 2000 March: 12(i). 35-48
4. Nandi DN, Ajmany S, Ganguli H, Baneree G. Borai GC, Grosn A. et a Tre Incidence of
mentai disorders in one year in a rural community in West Bengal. Indian Journal of
Psychiatry 1976: 18: 79-87.
5. Ramachandran V, Menon Sarada M, Arunagirt S. Socio-cultural factors in late onset
Depression. Indian Journal of Psychiatry 1982; 24(3), 268-73.
6. Kennedy Gary J, Kelman R Howard, Thomas Cynthia, Wisniewski Wendy Metz eer
Polly. Hierarchy of characteristics associated with Depressive Symptoms in an urDan
eioery sample. American Journal of Psychiatry 1989 February; 146(2): 220-25.
7. Dey AB, editor. Handbook on Health Care of the Elderly: A manual for physicians and in
Primary and Secondary Health Care Facilities. New Delhi: The World Health Organization:
Regiona’ Office for Southeast Asia, Ministry of Health and Family Welfare, All India
Institute of Medical Sciences (india); 1999.
8. Pareek U, Trivedi G. Manual of Soclo-economic Status Scale (rural). Delhi: Manasayan,
1980.
9. Nandi PS, Baneijee G, Mukherjee SP, Nandi S, Nandi DN. A study of Psychiatric morbidity
of the elderly population of a rural community in West Bengal. Indian Journal of
Psychiatry 1997: 39(2): 122-9.
10. Rao Venkoba A, Madhavan T. Geropsi r a semi-urban area near Madurai. Indian Journal
of Psychiat-y I S2 :
11. Newman SC, Bland RC, Cm Hi The me elderly in Edmonton: a community survey using
GMS-AGEC a-a ra 1998; 43: 910—14
12. Blazer Dan, Williams CD. Epidemiology of Dysphoria and Depression in an elderly
population American Journal of Psychiatry I 980; 137(4):439-44.
13. Penninx Brenda WJH, Leveille S,Ferrucci L, Eijk JTM, Guralnik JM. Exploring the
effect of depression on Physical disability longitudinal evidence from the established
populations for epidemiologic studies of the eldery. American Journal of Public Health
I999;89: 1 346-52.
14. Hamalainen J, Kaprio J, Isometsa E, Heikkinen M, Poikolainen K, Lindeman S, et al .
Cigarette smoking , alcohol intoxication an major depressive episode in a representative
population sample. Journal of Epidemiology and Community Health 2001; 55:573-76.
15. Ojen Van R, Hooijer C, Bezeme D. late life depressive disorder in the community, early
onset and the decrease of vulnerability with increasing age. Journal of Affective Disorders
1995; 33:1 59-65.
DEPRESSION IN ELDERLY:
A CROSS-SECTIONAL STUDY IN RURAL SOUTH INDIA
Ankur Barua, Das Acharya, K Nagaraj, H Vinod Bhat, NS Nair
Department of Community Medicine, Kasturba Medical College, Manipal, India
Abstract : The objectives of the study were to determine the prevalence of depression in elderly rural population and also study the sociodemographic
correlates of the depressive disorders among the elderly in this community. It was cross sectional study performed on the
elderly subjects of rural area of Udupi taluk Karnataka in South India over 8 months period. A total of 627 elderly individuals of age group
of 60 years and above, were interrogated : results were subjected to statistical analysis i.e proportions and their 95% confidence intervals,
Chi-square test, multiple logistic regression and its 95% confidence interval. The prevalence of depression in elderly population was
determined to be 21 .7%. The prevalence in the age group of 80 years and above and those individuals who had a history of death in the
family within the last six months were found to be 34.4% and 52.4%, respectively. Multiple logistic regression analysis revealed that these
two correlates were independently associated with depressive disorders in elderly population.
Key words: Depression, Prevalence, Correlates, Elderly, Multiple Logistic Regression
INTRODUCTION
The Indian aged population is currently the second largest in the world.
The proportion of those who would be aged 60 years and above is estimated
to be 7.7% for the year 2000, and this proportion is expected to reach
12.6% in 2025.1 A high prevalence of mental disorders is seen in old age.
Predominant among these is depression1. The future projections of global
DALY’s in the year 2020 show that mental disorders are projected to
increase to 15% of the global disease burden and unipolar major depression
could become the second leading cause disease burden after ischemic
heart disease12 especially in high-income countries. The communitybased
mental health studies have revealed that the point prevalence of
depressive disorders among the geriatric population in India varies between
13 and 25 percent According to the observations made by the World
Health Organization, the correlates -= disorders in old age are reported
as genetic susceptibility chronic disease and disability, pain,, frustration
with limitations in activities of daily living - events (widowhood, separation,
divorce, bereavement, poverty, social, isolation ) and lake of adequate
social support. Though depression is the commonest mental health
problem in old age, very few community-based studies had been conducted
in India, to understand the problem. No such study had been conducted
in the past in Udupi taluk of Karnataka. Considering this background, a
community-based mental health study was conducted in the rural area of
Udupi taluk to determine the disease burden of depressive disorders and
to study the correlates of depression among the elderly in the community.
MATERIAL AND METHODS
The rural field practice area of the Department of Community Medicine,
Kasturba Medical College, Manipal is located in the coastal area of Udupi
taluk in Udupi District of the state of Karnataka in South India. The total
geriatric population (>60yrs) in the field practice area is approximately
10.5% of the total population covered by the rural field practice area.
Study period: 8 months ( March to October 2002).
Setting: Three villages i.e.—Udayavara, Kadekar, and Katapady.
Study Design : Cross-sectional study.
The sample size was estimated for finite population with the help of EPIinfo
version 5.0 statistical package. The total geriatric population
(>=60yrs.) covered by the 3 RMCW homes was estimated to be of 2259.
Here, the confidence level was taken as 95%, 11 .2% prevalence rate of
depression, required relative precision of the estimate was set at 20% and
a non-response rate of 10% was included; hence, the final sample size
was determined as 627.
Sample size : 627 people in the age group of 60yrs and above, who were
permanent members of their respective households, were selected for the
study.
Sampling method : Simple Random Sampling ‘without replacement
method using the Probability proportionate to size (PPS) technique was
used.
Sampling Procedure - Exclusion criteria: If a designated house was
found locked during the first visit and the eligible residents could not be
contacted and even after 2 successive revisits then they were all excluded
from this study. Criteria For Defining A Non-Respondent: If a designated
respondent was non-cooperative or had severe behavioural problems or
cognitive impairment, had severe hearing impairment or articulation
disorder, had any terminal illness or if he could not be contacted during
two separate revisits after the first, then he was considered a non-respondent
Selection Procedure: Due to some on-going projects in some of the field
practice areas, only 3 centres out of the total 6 RMCW (Rural Maternity
And Child Welfare) Homes were chosen for our project As all the villages
in the field practice area are culturally and sacio-demographically identical,
this selection bias had minimal effect on the results, Using PPS (probability
proportionate to size) method, the required number of parucipants from
each village was decided. Then the households and parcipants were
randomly selected from updated family folders in RMCW homes using
the random number table. All the eligible candidates of the selected
households were interviewed as it was presumed that the effect of genetive
susceptbility would be minimal because only 4% of our study population
had either 1st degree or 2nd degree relatives residing together in the same
household.
Study Instruments: A fact sheet consisting of information regarding the
household of the respondent was used for data collection. A semi-structured
proforma containing information regarding the soclo-economic status of
the individual that was later estimated by the modified Udai Pareek Scale8
was also used, Presence of depressive disorders was determined using
the instrument Mastering Depression In Primary Care Version 2.2: It had
two components: (a) WHO (five) Well-being Index (1998 version), (b)
Major (lCD-b) Depression Inventory. Cognitive impairment was estimated
by the 6CIT Dementia Test. Mastering Depression In Primary Care Version
2.2 and the 6CIT Dementia Test were translated into Kannada and Hindi
by the researchers and back-translated into English by another expert, not
acquainted with the original versions. The back-translation was
subsequently compared with the original version by a psychiatrist for
conceptual equivalence of the items.
Organization Of Field Work And Data Collection
The investigator, along with three field ANMs (auxiliary nurse mid-wives),
Correspondence: Dr. Ankur Barua, Assistant Professor, Department
of Community Medicine Sikkim – Manipal Institute of Medical
Sciences (SMIMS) 5th Mile Tadong, Gangtok – 737 102 India
Fax.: 03592-231496, E-mail : ankurbarua26@yahoo.com
ORIGINAL
260 JIMSA October - December 2007 Vol. 20 No. 4
were trained by the psychiatrists on how to administer the questionnaires.
All our study instruments were pre-tested to determine whether they
optimally suited our field conditions. At the beginning, officials of the
local panchayat office, village leaders, Anganwadi workers and the ANMs
were contacted and their help was sought to understand the geography of
the sites and to trace the households. After informed verbal consent was
obtained, the designated respondent(s) of a particular household was
administered the selected sets of questionnaires by the investigator along
with the help of the field ANMs. Care was taken to ensure privacy and
confidentiality of the interview as part of the study. A brief general health
check-up of the respondent was conducted at the beginning to establish a
good rapport with him and also to gain his confidence. Alt the
questionnaires administered in the field were evaluated and rated on the
spot, and If a respondent became positive in any of our screening or
diagnostic instruments he was immediately handed over a referral slip
and sincerely requested to visit the psychiatry OPD of Kasturba Hospital,
Manipal at the earliest for a free consultancy. The participants having
obvious medical disorders were referred to the nearest RMCW homes
for a free health check-up. The diagnoses generated by the instruments in
our study were strictiy kept confidential and were reconfirmed by
consulting a senior faculty member of the department of psychiatry of
KMC Hospital, Manipal before arriving at a final lCD-b diagnosis for
data analysis.
Data Analysis
The collected data was tabulated and analysed by using the statistical
package SPSS (Statistical Package For Social Sciences) version 10.0 for
Windows. Findings were described in terms of proportions and their
95% confidence Intervals. chi-square test was applied to study the
relationship between different variables and depression. To determine
the independent effect of various factors on depressive disorders, multiple
logistic regression was performed and their significance was estimated in
terms of adjusted OR and its 95% confidence interval. P value less than
0.05 was considered as significant.
RESULTS AND DISCUSSION
During our field survey, 487 households were visited and 627 individuals
in the geriatric age group of 60 years and above were contacted. Among
these 627 elderly people, we could interview only 609 individuals for the
assessment of depressive disorders (97.1%), The 18 individuals, whom
we could not interview due to various reasons, were categorized as nonrespondents
(2.9%). The baseline characteristics of the population
surveyed revealed that 36.0% were males while 64.0% were females.
Majority (52.6%) belonged to the age group of (60-69) years. Only 58.7%
of the elderly were literates. Majority (61.2%) belonged to the middle
socio-economic status and 56.3% of the individuals were married.
The overall prevalence of depressive disorders among the elderly of 60
years and above was found to be 21.7% (95%Cl18.4-24.9). Our study
findings were consistent with the observations made by Nandi et a14,
West Bengal, Ramachandran V. et a15 Madras and Tiwari S.C. Lucknow,3
who had determined the prevalence of depressive disorders in the geriatric
population to be 22.0%, 24.1% and 13.5% respectively. However, a high
prevalence of depressive disorders of 52.2% among the elderly 60 years
was observed in the study conducted by Nandi et a19 in the rural areas of
West Bengal. In contrast to these observations, Rao Venkoba A. et al10
Madurai had recorded the prevalence of depression to be as low as 6.0%.
Studies conducted by Newman at Canada, and Kennedy et al6, USA
reported prevalence of depression among the elderly to be 11 .2% and
16.9%; respectively. We had also assessed the status of positive weltbeing
by using the WHO (Five) Well-Being index (version 1998). We
had observed that the prevalence of depressive disorders was high among
individuals whose status of positive well-being was poor (75.9%) as
compared to those who were satisfactory (5.3%). Table 1 Shows the
prevalence of depressive disorders according to various sociodemographic
correlates.
In this study, the prevalence of depressive disorders was higher among
females (22.6%) than males (19.9%), but this difference was not found to
be statistically significant (x2= 0.616, dt=1, p= 0.433). Our study findings
are consistent with the study by Blazer 12 (1979, North Carolina), where
the prevalence of depression was similar in both sexes. However, the
studies conducted by previous workers 5,6,11,13 had documented a high
prevalence of depression among the elderly females. Higher standards of
living, matriarchal family system and a high female literacy rate (94.6%)
could explain a lower prevalence of depression among females in our
study.
The age of the respondents ranged between 60to93 years, while the
mean age was found to be 69.0 years (SD6.8). The revalence of depressive
disorders was highest (34.4%) in the age group of 80 years and above.
The difference in prevalence of depression between different age groups
was found to be statistically significant (x2 9.932, df2, p0.007). The
prevalence of depressive disorders showed a positive linear trend of
increase with the progression of age, which was also found to be statistically
significant. Majority otud’pop were Hindus (80.1%). The prevalence of
depressive disorders did not vary widely among the Hindus (22.5%),
Christians (17.3%) and Muslims (20.0%) and the difference was not
found to be statistically significant. Similar findings were reported from a
study conducted by Tiwari3. The prevalence of depressive disorders was
high among the individuals belonging to the low economic status (SES)
group (25.2%) and high socia economic status (13.6%) groups. But the
difference between these groups was not found to be statiscally significant.
Studies conducted by several worker 5,6,13 had observed the prevelance of
depressive disorders to be significantly higher among the elderly belonging
to the low SES group.The prevalence of depressive disorders was similar
among the unmarried widowed or separated individuals (23.2%) as
compared to their married counterparts (20.5%). Our study findings were
not consistent with the previous studies 56 who had documented a
significantly high prevalence of depressive disorders among the widowed
individuals, in this study, we had observed that majority of the unmarried,
widowed or separated individuals were women (92.1%) with only a few
staying alone (5.6%) and deprived of any living child (5.2%). Better
JIMSA October - December 2007 Vol. 20 No. 4 261
standards of living, a satisfactory level of family support systems network,
high female literacy rate (94.6%) and matriarchal family system could
explain a lower prevalence of depression among these individuals in our
study.
In this study we found that the prevalence of depressive disorders remained
similar in case of both nuclear (20.6%) and print/extended families (22.2%).
The respondents, staying alone 16 (2.6%), were not included under nuclear
family. - ln this study, only 16 (2.6%) of the individuals were living alone.
The prevalence of depression among those who were staying alone, living
only with their children or relatives or living with their spouse was found
to be 18.8%, 22.9% and 20.8% respectively. But the difference between
these groups was not found to be statistically significant These findings
were in contrast with the studies conducted by Ramachandran5.
Blazer Dan12 and Kennedy Gary J.6 who had observed a significantly
high prevalence of depression among those living alone.
The prevalence of depressive disorders among illiterates was higher (254%)
as compared to literates (19.0%). The difference between the two groups
was however, not found to be statistically significant. Ramachandran V.15
‘Madrasad also reported similar observations. Studies conducted by
Kennedy et al16 and Penninx et al also reported a significantly higher
prevalence of depression among individuals with lower level of education.
None of the respondents were unemployed in the past. The proportion of
housewives affected with depressive disorders was 20.1%. The prevalence
of depressive disorders was almost similar among the unskilled (23.1%)
and skilled (24.5) labourers. Some of the previous 5,6 had reported a higher
prevalence of depression among the unemployed individuals.
As compared to smoking and alcohol consumption (17.2%), tobacco
chewing (39.2%) and pan chewing (49.9%) habits were common among
the geriatric population in Udupi Taluk. In this study, the prevalence of
depression was found to be significantly high among the having pan
chewing individuals (25.7%), tobacco chewing (26.1%) and alcohol
consumption (29.1%) habits. In a study conducted by Hämäläinen J. et
al14 from Finland, it was found that cigarette smoking and alcohol
consumption were important risk factors for major depressive episode.
The prevalence of depression was similar among those who gave a history
of psychiatric illness (19.5%) as compared to those without family history
of psychiatric illness (21.8%) and the difference between the groups was
not found to be statistically significant. These findings are in contrast with
the observations by Ojen Van15 who reported a significantly high prevalence
of depression among those with a positive family history of mental
disorders. This difference from our study might be due to social stigma
resulting in considerable number of under-reported and undiagnosed cases
of mental illness.
The prevalence of depression was high among the individuals who had a
history of death in their family within the last 6 months. The difference
between the two groups was found to be statistically significant . Similar
observations were also noted by Kennedy Gary6.
Table 2 describes the association between correlates of depressive disorders
according to the univariate as well as the multivariate analysis.
It was observed by univariate analysis age group of 80 years and above
and a history of death in the family within last 6 months had strong and
significant association with depressive disorders. However, Multiple
Logistic Regression analysis revealed that age group of eighty years and
above and a history of death in the family within last six months had
independent significant association with depressive disorders in the
geriatric population. These findings are consistent with the observations
from the study conducted by Kennedy Gary6.
CONCLUSIONS
In this study, the prevalence of depressive disorders among the geriatric
population was determined to be 21.7%. The prevalence rates of depression
among the males and females were 19.9% and 22.6%, respectively.
Multiple logistic regression analysis revealed that age group of 80 years
and above and a history of death in the family within the last six months
were indepenc1eny associated with depressive disorders in the geriatric
population.
LIMITATIONS
Due to feasibility constraints, we could not interview the people who
lived in the open and were homeless. Due to the lack of practical skills in
communication, we could not interview the non-respondents who were
having severe hearing impairment and aphasia. Since the proportion of
non-respondents and the individuals who were homeless was very small
in our study population, we expect only a minimal effect on our prevalence
estimate.
ACKNOWLEDGEMENTS
The authors would like to express their deep sense of gratitude to Dr. R.S.
Phaneendra Rao, Dean, Professor of Community Medicine, Kasturba
Medical College, Manipal for his invaluable support, critical evaluation
and skilled guidance throughout the study. The authors are also indebted
to Dr. N. Kar, Associate Professor, Department of Psychiatry, Kasturba
Medical College, Manipal for his technical guidance and valuable advice
on various aspects of psychiatric evaluation.
REFERENCES
1. The World Health Organization. World Health Report Mental Health: New understanding
New Hope. Geneva: The institute; 2001
2. Wig NN. World Health Day, 2001. Indian Journal of Psychiatry 2001; 43(1): 1-4.
3. Tiwari SC. Gerfa —Naffic morbidfty in ru:a riocthern India: implications for tne futjre
International Psychogenatrics 2000 March: 12(i). 35-48
4. Nandi DN, Ajmany S, Ganguli H, Baneree G. Borai GC, Grosn A. et a Tre Incidence of
mentai disorders in one year in a rural community in West Bengal. Indian Journal of
Psychiatry 1976: 18: 79-87.
5. Ramachandran V, Menon Sarada M, Arunagirt S. Socio-cultural factors in late onset
Depression. Indian Journal of Psychiatry 1982; 24(3), 268-73.
6. Kennedy Gary J, Kelman R Howard, Thomas Cynthia, Wisniewski Wendy Metz eer
Polly. Hierarchy of characteristics associated with Depressive Symptoms in an urDan
eioery sample. American Journal of Psychiatry 1989 February; 146(2): 220-25.
7. Dey AB, editor. Handbook on Health Care of the Elderly: A manual for physicians and in
Primary and Secondary Health Care Facilities. New Delhi: The World Health Organization:
Regiona’ Office for Southeast Asia, Ministry of Health and Family Welfare, All India
Institute of Medical Sciences (india); 1999.
8. Pareek U, Trivedi G. Manual of Soclo-economic Status Scale (rural). Delhi: Manasayan,
1980.
9. Nandi PS, Baneijee G, Mukherjee SP, Nandi S, Nandi DN. A study of Psychiatric morbidity
of the elderly population of a rural community in West Bengal. Indian Journal of
Psychiatry 1997: 39(2): 122-9.
10. Rao Venkoba A, Madhavan T. Geropsi r a semi-urban area near Madurai. Indian Journal
of Psychiat-y I S2 :
11. Newman SC, Bland RC, Cm Hi The me elderly in Edmonton: a community survey using
GMS-AGEC a-a ra 1998; 43: 910—14
12. Blazer Dan, Williams CD. Epidemiology of Dysphoria and Depression in an elderly
population American Journal of Psychiatry I 980; 137(4):439-44.
13. Penninx Brenda WJH, Leveille S,Ferrucci L, Eijk JTM, Guralnik JM. Exploring the
effect of depression on Physical disability longitudinal evidence from the established
populations for epidemiologic studies of the eldery. American Journal of Public Health
I999;89: 1 346-52.
14. Hamalainen J, Kaprio J, Isometsa E, Heikkinen M, Poikolainen K, Lindeman S, et al .
Cigarette smoking , alcohol intoxication an major depressive episode in a representative
population sample. Journal of Epidemiology and Community Health 2001; 55:573-76.
15. Ojen Van R, Hooijer C, Bezeme D. late life depressive disorder in the community, early
onset and the decrease of vulnerability with increasing age. Journal of Affective Disorders
1995; 33:1 59-65.
Need for a Realistic Mental Health Programme in India
48 Indian J Psychol Med | Jan - Jun 2009 | Vol 31 | Issue 1
Department of Community Medicine, Sikkim-Manipal Institute of Medical Sciences, Tadong, Gangtok, Sikkim, India
Address for correspondence: Dr. Ankur Barua,
Block-EE, No.-80, Flat No.-2A, Salt Lake City, Sector-2, Kolkata-700 091, West Bengal. India. E-mail: ankurbarua26@yahoo.com
DOI: 10.4103/0253-7176.53316
community in preventing as well as in promoting
mental health.
Need for a realistic mental health
programme in India[4-6]
India, with a population of a billion and very limited
numbers of mental health facilities and professionals
(one bed per 40,000 population and three psychiatrists
per million population), is confronting the complex
issues of providing mental health care to its entire
people. There are a few steps taken in the right direction,
namely the launching of the National Mental Health
Programme-NMHP (1982), adoption of Mental Health
Act (1987), persons with disability Act (1995), and
integration of the mental health with primary health
care at district level.
Though the implementation of the NMHP had
an initial spurt, but later, there were delays in its
expansion. Any programme howsoever well planned
cannot succeed unless there are no takers. There is an
urgent need for proper IEC, i.e. information, education,
and communication about the mental illness among
the masses. This will not only help in breaking the
Introduction
In India, at a given point of time, nearly 15 million
people suffer from serious psychiatric illness, and
another 30 million from mild/moderate psychiatric
problems.[1] The disability associated with mental or
brain disorders stops people from working and engaging
in other creative activities.[2]
Community care of mentally
challenged individuals[3]
Early in the 1960s and 1970s, it was beginning to be
realized that long-term institutional care of all the
needy mentally ill was neither possible nor desirable.
The answer was deinstitutionalisation and community
care. At that time, the best we could hope for was
compassionate custodial care within the four walls of
a mental asylum. These ill people were left there, often
for life, by their relatives and community, who would
then forget about them. It says a lot for the progress
made over the years, even in our country, that we
talk not only of treating mentally challenged patients
in their own surroundings, but also of involving the
India, with a population of a billion, has very limited numbers of mental health facilities and professionals in providing
mental health care to all the people. The disability associated with mental or brain disorders stops people from working
and engaging in other creative activities. Gradual implementation of district mental health programme in a phased
manner with support of adequate managerial and financial inputs is the need of the day. Trained mental health care
personnel, treatment, care, and rehabilitation facilities should be made available and accessible to the masses. The
voluntary organizations should be encouraged to participate in mental health care programme.
Key words: Community care, mentally challenged, realistic
Need for a Realistic Mental Health Programme in
India
Ankur Barua
ABSTRACT
New Horizon
Indian J Psychol Med | Jan - Jun 2009 | Vol 31 | Issue 1 49
Barua: Mental health programme
age-old myths and false beliefs about the mental illness
but also prevent the neglect of mentally ill and there
abandonment at places like Erwadi, in Tamil Nadu.
Inspiration to this effect can be taken from the fact
of extreme popularity of programmes like DATE on
Radio in 1992 and Mindwatch on TV in 1997. The
widespread availability and reach of media can be
further utilized for this purpose. Also extra care should
be taken to prevent misuse of media like films and
television for wrong depiction of mentally ill persons
and methods of treatment such as ECT.
The role of psychiatrists will be central in any effort that
is intended to be of benefit for the mentally challenged.
They should keep themselves updated about every
new change happening in the field of diagnosis and
treatment. The practice of evidence-based psychiatry
not only benefits patients but also increases the selfconfidence
of the professionals in this field about this
specialty and its scope.
The delay in development of support materials and
models at the district level and lack of facility for the
initiation and coordination of the large-scale expansion
of the mental health programme pose a serious
problem. The programme lacks an in-built evaluation
mechanism and has no space for continuous research
and community participation at the functional level.
The absence of a central organization for mental health
has been a serious constraint in postindependence
planning in India. Twenty out of twenty-five states
have not set up the State Mental Health Authority, as
in March 1996. A similar lag has been noticed in the
implementation of the Mental Health Act, in spite of
the fact that it was accepted by the parliament in 1987
and became operational since April 1993.
The impact of economic structural adjustment in
impoverishing people, the breakdown of traditional
community and family relationships caused by urban
migration, and the myriad adverse effects of newer
diseases like AIDS are likely to cause a greater impact
on people’s psychosocial health. In addition, these
programmes do not incorporate proper preventive
measures, even curative and rehabilitative services
provided are inadequate in terms of the estimated
needs. It is also clear that mental illness is a significant
cause of disability in India, which has been largely
ignored, in health related development activities.
There have been innovative initiatives in the private
sector in a number of areas of mental health. The most
notables of these are crisis intervention, rehabilitation
of the mentally challenged, and care of the elderly and
street children. However, this has mostly been at the
local level without adequate evaluation and expansion
to cover the rest of the country.
Gradual implementation of district mental health
programme in a phased manner with support of
adequate managerial and financial inputs is the need
of the day. Trained mental health care personnel,
treatment, care, and rehabilitation facilities should be
made available and accessible to the masses. This can
only be made possible by the sharing of responsibility
by government and nongovernment organizations
dedicated to the cause of mental health. The voluntary
organizations should be given greater importance, and
encouraged to participate to a larger extent in mental
health care programmes.
REFERENCES
1. The World Health Organization. Psychiatry and mental
health in India. Regional Office for South-East Asia: The
institute.
2. The World Health Organization. The World Health Report.
Geneva: The Institute; 1995.
3. Desai NG, Mohan I. Mental Health in South-East Asia:
Reaching out to the Community. Regional Health Forum. Vol. 5.
Southeast Asia Region: The World Health Organization.
4. Trivedi JK. Implication of Erwadi tragedy on mental
health care system in India. Indian Journal of Psychiatry
2001;43:292.
5. Murthy RS. Lesson from the Erwadi tragedy for mental
health care in India. Indian J Psychiatry 2001;43:362-78.
6. Selvaraj K, Kuruvilla K. In the aftermath of Erwadi incident.
Indian J Psychiatry 2001;43:362-78.
Source of Support: Nil, Conflict of Interest: None.
Department of Community Medicine, Sikkim-Manipal Institute of Medical Sciences, Tadong, Gangtok, Sikkim, India
Address for correspondence: Dr. Ankur Barua,
Block-EE, No.-80, Flat No.-2A, Salt Lake City, Sector-2, Kolkata-700 091, West Bengal. India. E-mail: ankurbarua26@yahoo.com
DOI: 10.4103/0253-7176.53316
community in preventing as well as in promoting
mental health.
Need for a realistic mental health
programme in India[4-6]
India, with a population of a billion and very limited
numbers of mental health facilities and professionals
(one bed per 40,000 population and three psychiatrists
per million population), is confronting the complex
issues of providing mental health care to its entire
people. There are a few steps taken in the right direction,
namely the launching of the National Mental Health
Programme-NMHP (1982), adoption of Mental Health
Act (1987), persons with disability Act (1995), and
integration of the mental health with primary health
care at district level.
Though the implementation of the NMHP had
an initial spurt, but later, there were delays in its
expansion. Any programme howsoever well planned
cannot succeed unless there are no takers. There is an
urgent need for proper IEC, i.e. information, education,
and communication about the mental illness among
the masses. This will not only help in breaking the
Introduction
In India, at a given point of time, nearly 15 million
people suffer from serious psychiatric illness, and
another 30 million from mild/moderate psychiatric
problems.[1] The disability associated with mental or
brain disorders stops people from working and engaging
in other creative activities.[2]
Community care of mentally
challenged individuals[3]
Early in the 1960s and 1970s, it was beginning to be
realized that long-term institutional care of all the
needy mentally ill was neither possible nor desirable.
The answer was deinstitutionalisation and community
care. At that time, the best we could hope for was
compassionate custodial care within the four walls of
a mental asylum. These ill people were left there, often
for life, by their relatives and community, who would
then forget about them. It says a lot for the progress
made over the years, even in our country, that we
talk not only of treating mentally challenged patients
in their own surroundings, but also of involving the
India, with a population of a billion, has very limited numbers of mental health facilities and professionals in providing
mental health care to all the people. The disability associated with mental or brain disorders stops people from working
and engaging in other creative activities. Gradual implementation of district mental health programme in a phased
manner with support of adequate managerial and financial inputs is the need of the day. Trained mental health care
personnel, treatment, care, and rehabilitation facilities should be made available and accessible to the masses. The
voluntary organizations should be encouraged to participate in mental health care programme.
Key words: Community care, mentally challenged, realistic
Need for a Realistic Mental Health Programme in
India
Ankur Barua
ABSTRACT
New Horizon
Indian J Psychol Med | Jan - Jun 2009 | Vol 31 | Issue 1 49
Barua: Mental health programme
age-old myths and false beliefs about the mental illness
but also prevent the neglect of mentally ill and there
abandonment at places like Erwadi, in Tamil Nadu.
Inspiration to this effect can be taken from the fact
of extreme popularity of programmes like DATE on
Radio in 1992 and Mindwatch on TV in 1997. The
widespread availability and reach of media can be
further utilized for this purpose. Also extra care should
be taken to prevent misuse of media like films and
television for wrong depiction of mentally ill persons
and methods of treatment such as ECT.
The role of psychiatrists will be central in any effort that
is intended to be of benefit for the mentally challenged.
They should keep themselves updated about every
new change happening in the field of diagnosis and
treatment. The practice of evidence-based psychiatry
not only benefits patients but also increases the selfconfidence
of the professionals in this field about this
specialty and its scope.
The delay in development of support materials and
models at the district level and lack of facility for the
initiation and coordination of the large-scale expansion
of the mental health programme pose a serious
problem. The programme lacks an in-built evaluation
mechanism and has no space for continuous research
and community participation at the functional level.
The absence of a central organization for mental health
has been a serious constraint in postindependence
planning in India. Twenty out of twenty-five states
have not set up the State Mental Health Authority, as
in March 1996. A similar lag has been noticed in the
implementation of the Mental Health Act, in spite of
the fact that it was accepted by the parliament in 1987
and became operational since April 1993.
The impact of economic structural adjustment in
impoverishing people, the breakdown of traditional
community and family relationships caused by urban
migration, and the myriad adverse effects of newer
diseases like AIDS are likely to cause a greater impact
on people’s psychosocial health. In addition, these
programmes do not incorporate proper preventive
measures, even curative and rehabilitative services
provided are inadequate in terms of the estimated
needs. It is also clear that mental illness is a significant
cause of disability in India, which has been largely
ignored, in health related development activities.
There have been innovative initiatives in the private
sector in a number of areas of mental health. The most
notables of these are crisis intervention, rehabilitation
of the mentally challenged, and care of the elderly and
street children. However, this has mostly been at the
local level without adequate evaluation and expansion
to cover the rest of the country.
Gradual implementation of district mental health
programme in a phased manner with support of
adequate managerial and financial inputs is the need
of the day. Trained mental health care personnel,
treatment, care, and rehabilitation facilities should be
made available and accessible to the masses. This can
only be made possible by the sharing of responsibility
by government and nongovernment organizations
dedicated to the cause of mental health. The voluntary
organizations should be given greater importance, and
encouraged to participate to a larger extent in mental
health care programmes.
REFERENCES
1. The World Health Organization. Psychiatry and mental
health in India. Regional Office for South-East Asia: The
institute.
2. The World Health Organization. The World Health Report.
Geneva: The Institute; 1995.
3. Desai NG, Mohan I. Mental Health in South-East Asia:
Reaching out to the Community. Regional Health Forum. Vol. 5.
Southeast Asia Region: The World Health Organization.
4. Trivedi JK. Implication of Erwadi tragedy on mental
health care system in India. Indian Journal of Psychiatry
2001;43:292.
5. Murthy RS. Lesson from the Erwadi tragedy for mental
health care in India. Indian J Psychiatry 2001;43:362-78.
6. Selvaraj K, Kuruvilla K. In the aftermath of Erwadi incident.
Indian J Psychiatry 2001;43:362-78.
Source of Support: Nil, Conflict of Interest: None.
A Study on Screening for Psychiatric Disorders in Adult Population
Indian Journal of Community Medicine Vol. 32, No. 1 (2007-01 - 2007-03)
A Study on Screening for Psychiatric Disorders in Adult Population
A Barua, GP Jacob, SS Mahmood, S Udupa, M Naidu, PS Roopa, SJ Puthiyadam
Department of Community Medicine, Kasturba Medical College, Manipal
Introduction
A study on psychiatric morbidity in Kukundoor village of Karkala taluk, Karnataka by Ajay K.T. (1999)1, using the SCAN 2.1 version (WHO, 1998) questionnaire, determined a one-month point prevalence of 63.8% of mental disorders. This was the first study conducted using Patient Health Questionnaire (PHQ) for screening mental health problems in adult population of Karkala.
Material and Methods
Karkala taluk belongs to Udupi district of Southern Karnataka. It has a population of 1,80,453 residing in 50 villages. Majority of the population are Hindus (85.8%), followed by Christians (7.7%), Muslims (6.4%) and Jains (1%). Study Period: 1 month (1st to 31st March 2004). Setting: Dr. TMA Pai Rotary Hospital, Karkala, Karnataka. Study Design: Cross-sectional study. Study Population: 193 adult individuals in the age group of 18 years and above participated in this study. Sampling Method: Purposive sampling method using the snowball technique was applied. Exclusion Criteria: All individuals, who were previously diagnosed as mentally challenged by the psychiatrists and those admitted in any in-patient ward of the hospital were excluded from this study.
Screening for psychiatric disorders was determined using the instrument Patient Health Questionnaire. This instrument was translated into Kannada and Hindi and again back-translated into English. The back-translation was subsequently compared with the original version by a psychiatrist for conceptual equivalence of the items.
Validation and Utility of a Self-Report Version of PRIME-MD2: Primary Care Evaluation of Mental Disorders (PRIME-MD) is clinical evaluation guide for physicians to assess four groups of mental disorders (mood, anxiety, alcohol and somatoform) and eating disorders. Agreement between PHQ diagnoses and those made by mental health practitioners was highly satisfactory (kappa = 0.65; overall accuracy = 85%; sensitivity = 75%; specificity = 90%).
The study instrument was pre-tested on a small group of individuals (n=10) on accounts of feasibility and acceptability. After informed verbal consent was obtained, a designated respondent was administered a selected set of questionnaires by the investigators. The diagnoses generated by the screening instrument were reconfirmed by consulting a psychiatrist before arriving at a final ICD-10 diagnosis for data analysis. Confirmed cases were given a referral slip and confidentially requested to visit the Psychiatry OPD of Dr. TMA Pai Rotary Hospital, Karkala at the earliest for a free consultancy.
The collected data was tabulated and analyzed by using the statistical package SPSS (Statistical Package for Social Sciences) version 10.0 for Windows. Findings were described in terms of proportions. Chi-square test was applied to study the relationship between different socio-demographic variables and psychiatric morbidity. p value less than 0.05 was considered as significant.
Results and Discussion
The baseline characteristics of the study population revealed that there were 43.5% males and 56.5% females. Majority of respondents (40.4%) belonged to the age group below 30 years. However, the mean age was found to be 35.2 years (SD=10.8). 72.0% of respondents were married, 69.9% were literates and 23.8% belonged to low socio-economic status (below poverty level).
Among a total of 193 individuals interviewed, 77(39.9%) were screened positive for psychiatric disorders. This was consistent with the observations made by Carstairs and Kapur (1976)3, who reported a case rate of 370 per 1000 population. However; this was less than the study by Ajay KT (1999)1, who reported a 1month point prevalence of mental disorders as 63.8% in adult population of Kukundoor village of Karkala taluk.
Among those having psychiatric disorders, majority 27(35.1%) were suffering from somatoform disorders, while 26(33.8%) from Major Depressive Disorder, 9(11.7%) from other Depressive Syndromes, 22(28.6%) from Panic Syndrome, 23(29.9%) from other Anxiety Syndromes, 3(3.9%) from Bulaemia Nervosum (eating disorders) and 5(6.5%) from Alcohol Abuse. Ajay KT (1999)1 also observed a high proportion of Mood Disorders (32.6%) and Anxiety Disorders (20.8%) in adult population of Kukundoor village of Karkala taluk. More than one diagnoses (mean=1.5, SD=0.55) was attributed to many of these cases. These observations were also consistent with the findings by Kessler et al (1994)4 who also reported major depressive episode, alcohol dependence, social phobia and simple phobia as most common psychiatric morbidities in adult population. In his study, women had higher prevalence than men of affective disorders, anxiety disorders and non-affective psychosis. Men had higher rates of substance use disorders and anti-social personality disorders.
Table 1 Shows the distribution of psychiatric disorders according to various socio demographic correlates. In this study, the proportion of psychiatric disorders was higher among females (42.2%) than males (36.9%), but this difference was not found to be statistically significant. The proportion of psychiatric disorders was highest (66.7%) in the age group of 50 years and above. The difference in proportion of psychiatric morbidity between different age groups was found to be statistically significant (x2= 10.97, df=3, p=0.012*).
The proportion of psychiatric disorders showed a positive linear trend of increase with the progression of age, which was also found to be statistically significant. Proportion of psychiatric disorders was significantly high (67.4%) among individuals belonging to low socio-economic status (below poverty level) and also among the unmarried, widowed or divorced individuals (61.1%) as compared to their married counterparts (31.7%). This is in contrast to the findings by Ajay KT (1999)1 who reported a high proportion of psychiatric morbidities among married individuals. Proportion of psychiatric disorders was significantly higher (63.8%) among illiterates.
Proportion of unemployed or housewives affected with psychiatric disorders was 68.4%. A significantly high proportion (72.7%) of psychiatric morbidities was observed among those who gave a positive family history of psychiatric illness and among those who lived alone (73.2%). Our findings were similar to the observations by Ojen Van et al (1995)5.
Conclusion
In this study, the proportion of mental illnesses in adult population was determined to be 39.9%. Proportion of psychiatric morbidity among males and females were 36.2% and 42.2% respectively. A statistical significant difference for psychiatric disorders was observed among the groups of socio-demographic correlates like age group of 50 years and above, those below poverty level, single individuals, illiterates, unemployed and housewives; living alone and a history of psychiatric illness in the family.
Acknowledgements
The authors are indebted to Prof. Ian Philip, Head, Department of Health Care for Elderly people, University of Sheffield, UK for providing the Patient Health Questionnaire (PHQ) and its validity and reliability statistics. Authors also extend their heartfelt gratitude to Dr. N. Kar, Ex-associate Professor, Department of Psychiatry, Kasturba Medical College, Manipal and Consultant Psychiatrist, Corner House Resource Centre, Wolverhampton, UK for his technical guidance and valuable advice on various aspects of psychiatric evaluation.
References
1. Ajay KT. Psychiatric morbidity in a rural low socioeconomic status population: An epidemiological field survey Kasturba Medical College, Manipal: Manipal Academy of Higher Education; July 2000.
2. Spitzer RL, Kroenke K, Williams JBW, and the Patient Health Questionnaire Primary Care Study Group. Validation and Utility of a Self-Report Version of PRIME-MD, JAMA, 1999; 282:1737-1744.
3. Carstairs GM, Kapur RL: The Great Universe of Kota; Stress, Change and Mental Disorders in an Indian Village. The Hogarth Press, London, 1976.
4. Kessler CR, McGonagle KA, Zhao S, Welson CB, Hughes M, Erchleman S et al: Lifefime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 1994; 51: 8-19.
5. Ojen VR, Hooijer C, Bezeme D. late life depressive disorder in the community, early onset and the decrease of vulnerability with increasing age. Journal of Affective Disorders, 1995; 33:159-65.
Table 1: Distribution of Psychiatric Disorders According to the Socio Demographic Correlates
Socio Demographic Correlates Number Of Subjects Interviewed
(N) Individuals With Psychiatric Morbidity
(N) Proportion of Psychiatric morbidity
(%) x2, df, p
1. Sex
Male 84 31 36.9 x2= 0.55, df=1, p=0.456
Female 109 46 42.2
2. Age Group (Years)
<30 78 24 30.8 x2 for linear trend=10.11,
p = 0.001*
30-39 55 20 36.4
40-49 36 17 47.2
≥50 24 16 66.7
3. Socio-Economic Status
Below poverty level 46 31 67.4 x2= 19.04, df=1, p= 0.0001*
Above poverty level 147 46 31.3
4. Marital Status
Unmarried/ Widowed/ Divorced 54 33 61.1 x2= 14.07, df=1, p= 0.0001*
Married 139 44 31.7
5. Religion
Jain 1 0 0.0 x2= 7.65, df=3, p= 0.054
Christian 14 1 7.1
Muslim 6 3 50.0
Hindu 172 73 42.4
6. Literacy Status
Illiterate 58 37 63.8 x2= 19.75, df=1, p= 0.0001*
Literate 135 40 29.6
7. Present Occupation
Unemployed / Housewife 76 52 68.4 x2= 49.38, df=3, p= 0.0001*
Unskilled 32 13 40.6
Skilled 52 7 13.5
Professional 33 5 15.2
8. Living arrangement in household
Living alone 41 30 73.2 x2= 27.90, df=2, p= 0.0001*
Living only with children & relatives 62 25 40.3
Living with spouse 90 22 24.4
9. Family History of
Psychiatric Illness
Present 11 8 72.7 x2= 5.24, df=1, p= 0.022*
Absent 182 69 37.9
10. History of death in family within last 6 months
Present 35 10 28.6 x2= 2.29, df=1, p= 0.130
Absent 158 67 42.4
* p value <0.05 is considered as significant
A Study on Screening for Psychiatric Disorders in Adult Population
A Barua, GP Jacob, SS Mahmood, S Udupa, M Naidu, PS Roopa, SJ Puthiyadam
Department of Community Medicine, Kasturba Medical College, Manipal
Introduction
A study on psychiatric morbidity in Kukundoor village of Karkala taluk, Karnataka by Ajay K.T. (1999)1, using the SCAN 2.1 version (WHO, 1998) questionnaire, determined a one-month point prevalence of 63.8% of mental disorders. This was the first study conducted using Patient Health Questionnaire (PHQ) for screening mental health problems in adult population of Karkala.
Material and Methods
Karkala taluk belongs to Udupi district of Southern Karnataka. It has a population of 1,80,453 residing in 50 villages. Majority of the population are Hindus (85.8%), followed by Christians (7.7%), Muslims (6.4%) and Jains (1%). Study Period: 1 month (1st to 31st March 2004). Setting: Dr. TMA Pai Rotary Hospital, Karkala, Karnataka. Study Design: Cross-sectional study. Study Population: 193 adult individuals in the age group of 18 years and above participated in this study. Sampling Method: Purposive sampling method using the snowball technique was applied. Exclusion Criteria: All individuals, who were previously diagnosed as mentally challenged by the psychiatrists and those admitted in any in-patient ward of the hospital were excluded from this study.
Screening for psychiatric disorders was determined using the instrument Patient Health Questionnaire. This instrument was translated into Kannada and Hindi and again back-translated into English. The back-translation was subsequently compared with the original version by a psychiatrist for conceptual equivalence of the items.
Validation and Utility of a Self-Report Version of PRIME-MD2: Primary Care Evaluation of Mental Disorders (PRIME-MD) is clinical evaluation guide for physicians to assess four groups of mental disorders (mood, anxiety, alcohol and somatoform) and eating disorders. Agreement between PHQ diagnoses and those made by mental health practitioners was highly satisfactory (kappa = 0.65; overall accuracy = 85%; sensitivity = 75%; specificity = 90%).
The study instrument was pre-tested on a small group of individuals (n=10) on accounts of feasibility and acceptability. After informed verbal consent was obtained, a designated respondent was administered a selected set of questionnaires by the investigators. The diagnoses generated by the screening instrument were reconfirmed by consulting a psychiatrist before arriving at a final ICD-10 diagnosis for data analysis. Confirmed cases were given a referral slip and confidentially requested to visit the Psychiatry OPD of Dr. TMA Pai Rotary Hospital, Karkala at the earliest for a free consultancy.
The collected data was tabulated and analyzed by using the statistical package SPSS (Statistical Package for Social Sciences) version 10.0 for Windows. Findings were described in terms of proportions. Chi-square test was applied to study the relationship between different socio-demographic variables and psychiatric morbidity. p value less than 0.05 was considered as significant.
Results and Discussion
The baseline characteristics of the study population revealed that there were 43.5% males and 56.5% females. Majority of respondents (40.4%) belonged to the age group below 30 years. However, the mean age was found to be 35.2 years (SD=10.8). 72.0% of respondents were married, 69.9% were literates and 23.8% belonged to low socio-economic status (below poverty level).
Among a total of 193 individuals interviewed, 77(39.9%) were screened positive for psychiatric disorders. This was consistent with the observations made by Carstairs and Kapur (1976)3, who reported a case rate of 370 per 1000 population. However; this was less than the study by Ajay KT (1999)1, who reported a 1month point prevalence of mental disorders as 63.8% in adult population of Kukundoor village of Karkala taluk.
Among those having psychiatric disorders, majority 27(35.1%) were suffering from somatoform disorders, while 26(33.8%) from Major Depressive Disorder, 9(11.7%) from other Depressive Syndromes, 22(28.6%) from Panic Syndrome, 23(29.9%) from other Anxiety Syndromes, 3(3.9%) from Bulaemia Nervosum (eating disorders) and 5(6.5%) from Alcohol Abuse. Ajay KT (1999)1 also observed a high proportion of Mood Disorders (32.6%) and Anxiety Disorders (20.8%) in adult population of Kukundoor village of Karkala taluk. More than one diagnoses (mean=1.5, SD=0.55) was attributed to many of these cases. These observations were also consistent with the findings by Kessler et al (1994)4 who also reported major depressive episode, alcohol dependence, social phobia and simple phobia as most common psychiatric morbidities in adult population. In his study, women had higher prevalence than men of affective disorders, anxiety disorders and non-affective psychosis. Men had higher rates of substance use disorders and anti-social personality disorders.
Table 1 Shows the distribution of psychiatric disorders according to various socio demographic correlates. In this study, the proportion of psychiatric disorders was higher among females (42.2%) than males (36.9%), but this difference was not found to be statistically significant. The proportion of psychiatric disorders was highest (66.7%) in the age group of 50 years and above. The difference in proportion of psychiatric morbidity between different age groups was found to be statistically significant (x2= 10.97, df=3, p=0.012*).
The proportion of psychiatric disorders showed a positive linear trend of increase with the progression of age, which was also found to be statistically significant. Proportion of psychiatric disorders was significantly high (67.4%) among individuals belonging to low socio-economic status (below poverty level) and also among the unmarried, widowed or divorced individuals (61.1%) as compared to their married counterparts (31.7%). This is in contrast to the findings by Ajay KT (1999)1 who reported a high proportion of psychiatric morbidities among married individuals. Proportion of psychiatric disorders was significantly higher (63.8%) among illiterates.
Proportion of unemployed or housewives affected with psychiatric disorders was 68.4%. A significantly high proportion (72.7%) of psychiatric morbidities was observed among those who gave a positive family history of psychiatric illness and among those who lived alone (73.2%). Our findings were similar to the observations by Ojen Van et al (1995)5.
Conclusion
In this study, the proportion of mental illnesses in adult population was determined to be 39.9%. Proportion of psychiatric morbidity among males and females were 36.2% and 42.2% respectively. A statistical significant difference for psychiatric disorders was observed among the groups of socio-demographic correlates like age group of 50 years and above, those below poverty level, single individuals, illiterates, unemployed and housewives; living alone and a history of psychiatric illness in the family.
Acknowledgements
The authors are indebted to Prof. Ian Philip, Head, Department of Health Care for Elderly people, University of Sheffield, UK for providing the Patient Health Questionnaire (PHQ) and its validity and reliability statistics. Authors also extend their heartfelt gratitude to Dr. N. Kar, Ex-associate Professor, Department of Psychiatry, Kasturba Medical College, Manipal and Consultant Psychiatrist, Corner House Resource Centre, Wolverhampton, UK for his technical guidance and valuable advice on various aspects of psychiatric evaluation.
References
1. Ajay KT. Psychiatric morbidity in a rural low socioeconomic status population: An epidemiological field survey Kasturba Medical College, Manipal: Manipal Academy of Higher Education; July 2000.
2. Spitzer RL, Kroenke K, Williams JBW, and the Patient Health Questionnaire Primary Care Study Group. Validation and Utility of a Self-Report Version of PRIME-MD, JAMA, 1999; 282:1737-1744.
3. Carstairs GM, Kapur RL: The Great Universe of Kota; Stress, Change and Mental Disorders in an Indian Village. The Hogarth Press, London, 1976.
4. Kessler CR, McGonagle KA, Zhao S, Welson CB, Hughes M, Erchleman S et al: Lifefime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 1994; 51: 8-19.
5. Ojen VR, Hooijer C, Bezeme D. late life depressive disorder in the community, early onset and the decrease of vulnerability with increasing age. Journal of Affective Disorders, 1995; 33:159-65.
Table 1: Distribution of Psychiatric Disorders According to the Socio Demographic Correlates
Socio Demographic Correlates Number Of Subjects Interviewed
(N) Individuals With Psychiatric Morbidity
(N) Proportion of Psychiatric morbidity
(%) x2, df, p
1. Sex
Male 84 31 36.9 x2= 0.55, df=1, p=0.456
Female 109 46 42.2
2. Age Group (Years)
<30 78 24 30.8 x2 for linear trend=10.11,
p = 0.001*
30-39 55 20 36.4
40-49 36 17 47.2
≥50 24 16 66.7
3. Socio-Economic Status
Below poverty level 46 31 67.4 x2= 19.04, df=1, p= 0.0001*
Above poverty level 147 46 31.3
4. Marital Status
Unmarried/ Widowed/ Divorced 54 33 61.1 x2= 14.07, df=1, p= 0.0001*
Married 139 44 31.7
5. Religion
Jain 1 0 0.0 x2= 7.65, df=3, p= 0.054
Christian 14 1 7.1
Muslim 6 3 50.0
Hindu 172 73 42.4
6. Literacy Status
Illiterate 58 37 63.8 x2= 19.75, df=1, p= 0.0001*
Literate 135 40 29.6
7. Present Occupation
Unemployed / Housewife 76 52 68.4 x2= 49.38, df=3, p= 0.0001*
Unskilled 32 13 40.6
Skilled 52 7 13.5
Professional 33 5 15.2
8. Living arrangement in household
Living alone 41 30 73.2 x2= 27.90, df=2, p= 0.0001*
Living only with children & relatives 62 25 40.3
Living with spouse 90 22 24.4
9. Family History of
Psychiatric Illness
Present 11 8 72.7 x2= 5.24, df=1, p= 0.022*
Absent 182 69 37.9
10. History of death in family within last 6 months
Present 35 10 28.6 x2= 2.29, df=1, p= 0.130
Absent 158 67 42.4
* p value <0.05 is considered as significant
Subscribe to:
Posts (Atom)
