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1.  Women's health in a rural community in Kerala, India: do caste and socioeconomic position matter? 
Objectives
To examine the social patterning of women's self‐reported health status in India and the validity of the two hypotheses: (1) low caste and lower socioeconomic position is associated with worse reported health status, and (2) associations between socioeconomic position and reported health status vary across castes.
Design
Cross‐sectional household survey, age‐adjusted percentages and odds ratios, and multilevel multinomial logistic regression models were used for analysis.
Setting
A panchayat (territorial decentralised unit) in Kerala, India, in 2003.
Participants
4196 non‐elderly women.
Outcome measures
Self‐perceived health status and reported limitations in activities in daily living.
Results
Women from lower castes (scheduled castes/scheduled tribes (SC/ST) and other backward castes (OBC) reported a higher prevalence of poor health than women from forward castes. Socioeconomic inequalities were observed in health regardless of the indicators, education, women's employment status or household landholdings. The multilevel multinomial models indicate that the associations between socioeconomic indicators and health vary across caste. Among SC/ST and OBC women, the influence of socioeconomic variables led to a “magnifying” effect, whereas among forward caste women, a “buffering” effect was found. Among lower caste women, the associations between socioeconomic factors and self‐assessed health are graded; the associations are strongest when comparing the lowest and highest ratings of health.
Conclusions
Even in a relatively egalitarian state in India, there are caste and socioeconomic inequalities in women's health. Implementing interventions that concomitantly deal with caste and socioeconomic disparities will likely produce more equitable results than targeting either type of inequality in isolation.
doi:10.1136/jech.2006.047647
PMCID: PMC2465509  PMID: 17108296
2.  Health education for microcredit clients in Peru: a randomized controlled trial 
BMC Public Health  2011;11:51.
Background
Poverty, lack of female empowerment, and lack of education are major risk factors for childhood illness worldwide. Microcredit programs, by offering small loans to poor individuals, attempt to address the first two of these risk factors, poverty and gender disparity. They provide clients, usually women, with a means to invest in their businesses and support their families. This study investigates the health effects of also addressing the remaining risk factor, lack of knowledge about important health issues, through randomization of members of a microcredit organization to receive a health education module based on the World Health Organization's Integrated Management of Childhood Illness (IMCI) community intervention.
Methods
Baseline data were collected in February 2007 from clients of a microcredit organization in Pucallpa, Peru (n = 1,855) and their children (n = 598). Loan groups, consisting of 15 to 20 clients, were then randomly assigned to receive a health education intervention involving eight monthly 30-minute sessions given by the organization's loan officers at monthly loan group meetings. In February 2008, follow-up data were collected, and included assessments of sociodemographic information, knowledge of child health issues, and child health status (including child height, weight, and blood hemoglobin levels). To explore the effects of treatment (i.e., participation in the health education sessions) on the key outcome variables, multivariate regressions were implemented using ordinary least squares.
Results
Individuals in the IMCI treatment arm demonstrated more knowledge about a variety of issues related to child health, but there were no changes in anthropometric measures or reported child health status.
Conclusions
Microcredit clients randomized to an IMCI educational intervention showed greater knowledge about child health, but no differences in child health outcomes compared to controls. These results imply that the intervention did not have sufficient intensity to change behavior, or that microcredit organizations may not be an appropriate setting for the administration of child health educational interventions of this type.
Trial Registration
This study is registered with ClinicalTrials.gov, NCT01047033.
doi:10.1186/1471-2458-11-51
PMCID: PMC3037866  PMID: 21261988
3.  The effect of Self-Help Groups on access to maternal health services: evidence from rural India 
Introduction
The main challenge for achieving universal health coverage in India is ensuring effective coverage of poor and vulnerable communities in the face of high levels of income and gender inequity in access to health care. Drawing on the social capital generated through women’s participation in community organizations like SHGs can influence health outcomes. To date, evidence about the impact of SHGs on health outcomes has been derived from pilot-level interventions, some using randomised controlled trials and other rigorous methods. While the evidence from these studies is convincing, our study is the first to analyse the impact of SHGs at national level.
Methods
We analyzed the entire dataset from the third national District Level Household Survey from 601 districts in India to assess the impact of the presence of SHGs on maternal health service uptake. The primary predictor variable was presence of a SHG in the village. The outcome variables were: institutional delivery; feeding new-borns colostrum; knowledge about family planning methods; and ever used family planning. We controlled for respondent education, wealth, heard or seen health messages, availability of health facilities and the existence of a village health and sanitation committee.
Results
Stepwise logistic regression shows respondents from villages with a SHG were 19 per cent (OR: 1.19, CI: 1.13-1.24) more likely to have delivered in an institution, 8 per cent (OR: 1.08, CI: 1.05-1.14) more likely to have fed newborns colostrum, have knowledge (OR: 1.48, CI 1.39 – 1.57) and utilized (OR: 1.19, CI 1.11 – 1.27) family planning products and services. These results are significant after controlling for individual and village-level heterogeneities and are consistent with existing literature that the social capital generated through women’s participation in SHGs influences health outcome.
Conclusion
The study concludes that the presence of SHGs in a village is associated with higher knowledge of family planning and maternal health service uptake in rural India. To achieve the goal of improving public health nationally, there is a need to understand more fully the benefits of systematic collaboration between the public health community and these grassroots organizations.
doi:10.1186/1475-9276-12-36
PMCID: PMC3673812  PMID: 23714337
Self help group; Institutional delivery; Family planning; Barriers; India
4.  Sitting with others: mental health self-help groups in northern Ghana 
Background
Over the past four decades, there has been increasing interest in Self-Help Groups, by mental health services users and caregivers, alike. Research in high-income countries suggests that participation in SHGs is associated with decreased use of inpatient facilities, improved social functioning among service users, and decreased caregiver burden. The formation of SHGs has become an important component of mental health programmes operated by non-governmental organisations (NGOs) in low-income countries. However, there has been relatively little research examining the benefits of SHGs in this context.
Methods
Qualitative research with 18 SHGs, five local non-governmental organisations, community mental health nurses, administrators in Ghana Health Services, and discussions with BasicNeeds staff.
Results
SHGs have the potential to serve as key components of community mental health programmes in low-resource settings. The strongest evidence concerns how SHGs provide a range of supports, e.g., social, financial, and practical, to service users and caregivers. The groups also appear to foster greater acceptance of service users by their families and by communities at large. Membership in SHGs appears to be associated with more consistent treatment and better outcomes for those who are ill.
Discussion
This study highlights the need for longitudinal qualitative and quantitative evaluations of the effect of SHGs on clinical, social and economic outcomes of service users and their carers.
Conclusions
The organisation of SHGs appears to be associated with positive outcomes for service users and caregivers. However, there is a need to better understand how SHGs operate and the challenges they face.
doi:10.1186/1752-4458-6-1
PMCID: PMC3366888  PMID: 22436354
5.  A Qualitative Exploration of the Economic and Social Effects of Microcredit among People Living with HIV/AIDS in Uganda 
AIDS Research and Treatment  2012;2012:318957.
HIV medical care, including antiretroviral therapy (ART), is often successful in restoring physical health and functioning. But in developing countries, HIV medical care is often insufficient to achieve social and economic health, and hence innovative economic support programs are much needed. We conducted semistructured interviews with 30 adults receiving ART and microcredit loans operated by Uganda Cares. Using content analysis, we explored the impact of the microcredit loans on the economic, social, and psychological well-being of respondents. Most respondents indicated that the microcredit loans played a positive role in their lives, helped them to keep their children in school and sustain their families, and improved their self-esteem and status in the community. In addition, we also found significant positive knowledge spill-over and network effects in the program with regard to business management and support. However, more than half of the participants indicated experiencing repayment problems either personally or with other group members due to unexpected emergencies and sickness. These findings highlight that microcredit programs have the potential of being an economic support system for HIV clients trying to reestablish their livelihoods, especially in resource-constrained settings, though more research is needed to determine the overall economic viability of such programs.
doi:10.1155/2012/318957
PMCID: PMC3388281  PMID: 22778923
6.  Cervical cancer screening: Current knowledge & practice among women in a rural population of Kerala, India 
Background & objectives:
Cervical cancer has a major impact on woman's lives worldwide and one in every five women suffering from cervical cancer belongs to India. Hence the objectives of this study were to find the knowledge of women regarding cervical cancer, to determine screening practices and determinants, and to identify factors for non screening.
Methods:
A cross-sectional study was conducted in Vypin Block of Ernakulam District, Kerala, India where four of the seven Panchayats were randomly chosen. Households were selected by systematic random sampling taking every second house in the tenth ward of the Panchayat till at least 200 women were interviewed. Thus, 809 women were interviewed from four Panchayats.
Results:
Mean age of the study population was 34.5 + 9.23 yr. Three fourths of the population (74.2%) knew that cervical cancer could be detected early by a screening test. Majority of respondents (89.2%) did not know any risk factor for cervical cancer. Of the 809 women studied, only 6.9 per cent had undergone screening. One third of the population were desirous of undergoing screening test but had not done it due to various factors. These factors related to knowledge (51.4%) such as no symptoms, not being aware of Pap test, not necessary, etc. This was followed by resource factors (15.1%) like no time, no money, etc. and psychosocial factors (10.2%) included lack of interest, fear of procedure, etc. Independent predictors for doing Pap test included age >35, having knowledge of screening for cervical cancer and Pap test (P<0.05).
Interpretation & conclusions:
Specific knowledge on cervical cancer screening is a critical element in determining whether a woman will undergo Pap test in addition to making cancer screening facilities available in the primary health centre.
PMCID: PMC3461731  PMID: 22960886
Cervical cancer; knowledge; practice; screening
7.  Debt, shame, and survival: becoming and living as widows in rural Kerala, India 
Background
The health and well-being of widows in India is an important but neglected issue of public health and women’s rights. We investigate the lives of Indian women as they become widows, focussing on the causes of their husband’s mortality and the ensuing consequences of these causes on their own lives and identify the opportunities and challenges that widows face in living healthy and fulfilling lives.
Methods
Data were collected in a Gram Panchayat (lowest level territorial decentralised unit) in the south Indian state of Kerala. Interviews were undertaken with key informants in order to gain an understanding of local constructions of ‘widowhood’ and the welfare and social opportunities for widows. Then we conducted semi-structured interviews with widows in the community on issues related to health and vulnerability, enabling us to hear perspectives from widows. Data were analysed for thematic content and emerging patterns. We synthesized our findings with theoretical understandings of vulnerability and Amartya Sen’s entitlements theory to develop a conceptual framework.
Results
Two salient findings of the study are: first, becoming a widow can be viewed as a type of ‘shock’ that operates similarly to other ‘economic shocks’ or ‘health shocks’ in poor countries except that the burden falls disproportionately on women. Second, widowhood is not a static phenomenon, but rather can be viewed as a multi-phased process with different public health implications at each stage.
Conclusion
More research on widows in India and other countries will help to both elucidate the challenges faced by widows and encourage potential solutions. The framework developed in this paper could be used to guide future research on widows.
doi:10.1186/1472-698X-12-28
PMCID: PMC3517387  PMID: 23126457
8.  Assessment of Status of Patients Receiving Palliative Home Care and Services Provided in a Rural Area—Kerala, India 
Indian Journal of Palliative Care  2012;18(3):213-218.
Context:
For the first time in India, a Pain and Palliative Care policy to guide the community-based home care initiatives was declared by the Government of Kerala state. In Kerala, majority of the panchayats (local self-governments) are now conducting home-based palliative care as part of primary health care. National focus domain areas in palliative care research are structure and process, the physical aspects, and also the social aspects of care.
Aims:
The study was conducted to assess the patient's status and the services provided by palliative home care.
Settings and Design:
The descriptive study was conducted at Mavoor panchayat—Kozhikode district of Kerala, India by collecting information from the case records, nurses diary notes of all enrolled patients.
Materials and Methods:
Collecting information from the case records, nurses diary notes of all enrolled patients.
Statistical Analysis:
The data were entered using Microsoft excel for Windows XP and analyzed using SPSS 16.0 (Statistical Package for Social Sciences; SPSS Inc., Chicago, IL, USA).
Results:
Totally, 104 patients were enrolled. Diagnosis wise major category was degenerative diseases. There were 27% persons suffering from cerebrovascular accidents, 15.3% with malignancies, 8.7% with coronary artery disease, 5.8% with complications of diabetes, and 8.7% were with fracture of bones. The major complaints were weakness (41.3%), tiredness (31.7%), and pain (27%). Twenty-five percent persons complained of urinary incontinence, 12.5% complained of ulcer, 10.6% of edema, and 9.6% of mental/emotional agony. The activity of daily living status was as follows. Twenty-five percent subjects were completely bed ridden. 5.8% were feeding through Ryles tube, 16.3% had urinary incontinence, 9.6% were having no bowel control.
Conclusions:
The service could address most of the medical, psychosocial, and supportive needs of the patients and reduce their pain and symptoms. The interface between institutional-based care and home care needs more exploration and prospective studies.
doi:10.4103/0973-1075.105693
PMCID: PMC3573477  PMID: 23440060
Activity of daily living; Community nurse; Home-based palliative care; Primary care; Quality of life
9.  Community-Based Mental Health Intervention for Underprivileged Women in Rural India: An Experiential Report 
Objective. To share experiences from a project that integrates a mental health intervention within a developmental framework of microcredit activity for economically underprivileged women in rural India. Method. The mental health intervention had two components: group counseling and stress management. The former comprised of ventilation and reassurance and the latter strengthening of coping skills and a relaxation technique. Focus group discussions were used to understand women's perception of how microcredit economic activity and the mental health intervention had affected their lives. Results. Women in the mental health intervention group reported reduction in psychological distress and bodily aches and pains. Majority (86%) reported that the quality of their sleep had improved with regular practice of relaxation and that sharing their problems in the group had helped them to unburden. The social support extended by the members to each other, made them feel that they were not alone and could face any life situation. Conclusion. The study provided qualitative evidence that adding the mental health intervention to the ongoing economic activity had made a positive difference in the lives of the women. Addressing mental health concerns along with livelihood initiatives can help to enhance both economic and social capital in rural poor women.
doi:10.1155/2011/621426
PMCID: PMC3263843  PMID: 22295190
10.  Utilisation of rheumatology care services in Germany: the case of physical therapy and self-help groups 
Physical Therapy (PT) and self-help groups (SHG) are important components of health care in rheumatic diseases. The utilisation of PT and SHG by patients with rheumatic diseases may be influenced by several factors. The aim of this study is to summarize the evidence on PT and SHG utilisation of patients with rheumatic diseases in Germany. We systematically searched the MEDLINE-database for studies that evaluated the utilisation and factors that possibly influence the utilisation of PT and SHG. Eight studies were found for PT-utilisation and one for SHG-utilisation. Between 25 and 59 percent of patients with rheumatic diseases received PT services. Several individual and contextual factors that may influence the utilisation could be identified. In conclusion, evidence exists for wide variations in the utilisation of PT services and an underuse of such services among patients with rheumatic diseases in Germany. By contrast, little evidence exists on the utilisation of SHG.
doi:10.3205/psm000086
PMCID: PMC3488804  PMID: 23133502
rheumatic disease; physical therapy; self-help; utilisation
11.  Promoting Household Water Treatment through Women's Self Help Groups in Rural India: Assessing Impact on Drinking Water Quality and Equity 
PLoS ONE  2012;7(9):e44068.
Household water treatment, including boiling, chlorination and filtration, has been shown effective in improving drinking water quality and preventing diarrheal disease among vulnerable populations. We used a case-control study design to evaluate the extent to which the commercial promotion of household water filters through microfinance institutions to women's self-help group (SHG) members improved access to safe drinking water. This pilot program achieved a 9.8% adoption rate among women targeted for adoption. Data from surveys and assays of fecal contamination (thermotolerant coliforms, TTC) of drinking water samples (source and household) were analyzed from 281 filter adopters and 247 non-adopters exposed to the program; 251 non-SHG members were also surveyed. While adopters were more likely than non-adopters to have children under 5 years, they were also more educated, less poor, more likely to have access to improved water supplies, and more likely to have previously used a water filter. Adopters had lower levels of fecal contamination of household drinking water than non-adopters, even among those non-adopters who treated their water by boiling or using traditional ceramic filters. Nevertheless, one-third of water samples from adopter households exceeded 100 TTC/100ml (high risk), and more than a quarter of the filters had no stored treated water available when visited by an investigator, raising concerns about correct, consistent use. In addition, the poorest adopters were less likely to see improvements in their water quality. Comparisons of SHG and non-SHG members suggest similar demographic characteristics, indicating SHG members are an appropriate target group for this promotion campaign. However, in order to increase the potential for health gains, future programs will need to increase uptake, particularly among the poorest households who are most susceptible to disease morbidity and mortality, and focus on strategies to improve the correct, consistent and sustained use of these water treatment products.
doi:10.1371/journal.pone.0044068
PMCID: PMC3434210  PMID: 22957043
12.  Capability Development among the Ultra-poor in Bangladesh: A Case Study 
Microcredit is advocated as a development tool that has the potential to reduce poverty, empower participants, and improve health. Results of several studies have shown that the extreme poor, or the ultra-poor, often are unable to benefit from traditional microcredit programmes and can, as a result of taking a loan they cannot repay, sink deeper into economic and social poverty. This case study describes an intervention directed at enabling the ultra-poor rural populations to pull themselves out of poverty. The intervention integrates multiple components, including asset grants for income generation, skills training, a time-bound monthly stipend for subsistence, social development and mobilization of local elite, and health support. Results of an evaluation showed that, after 18 months, the programme positively impacted livelihood, economic, social and health status to the extent that 63% of households (n=5,000) maintained asset growth and joined (or intended to join) a regular microcredit programme. Impacts included improved income, improved food security, and improved health knowledge and behaviour. Applying a social exclusion framework to the intervention helps identify the different dynamic forces that can exclude or include the ultra-poor in Bangladesh in development interventions such as microcredit.
PMCID: PMC2928093  PMID: 19761086
Capacity-building; Economic assistance; Poverty; Ultra-poor; Bangladesh
13.  Suicide in South India: A community-based study in Kerala 
Indian Journal of Psychiatry  2009;51(4):261-264.
Background:
Studies from Tamil Nadu, South India, have reported the world's highest suicide rates. As per official reports, Kerala, another South Indian state has the highest suicide rate among the major states in India.
Objective:
The purpose of this analysis is to estimate the rates and age-specific incidence of suicide in a rural community in Kerala, under continuous observation for the last five years.
Settings and Design:
The study setting comprised of seven contiguous panchayats constituting a development block in Kerala. A prospective cohort study design was used.
Materials and Methods:
Through regular home visits, every death that occurred in the community was captured by local resident health workers and the cause of death assigned.
Statistical Analysis:
Suicide rates by age and sex and relative share of suicide deaths to all-cause deaths in men and women were calculated.
Results:
During the five-year period from 2002 to 2007, 284 cases of suicide were reported. The suicide rates were 44.7/100,000 for males and 26.8/100,000 for females. Male to female suicide ratio was 1.7. Among females aged between 15 and 24, suicides constituted more than 50% of all deaths. Male to female ratio of suicide varied from 0.4 in children aged 14 years or less to 4.5 in the 45-54 year age group.
Conclusion:
Our analysis shows that the level of under-reporting of suicides in rural Kerala is much less than that reported in Tamil Nadu.
doi:10.4103/0019-5545.58290
PMCID: PMC2802372  PMID: 20048450
Kerala; South India; suicide
14.  Social class related inequalities in household health expenditure and economic burden: evidence from Kerala, south India 
Background
In the Indian context, a household's caste characteristics are most relevant for identifying its poverty and vulnerability status. Inadequate provision of public health care, the near-absence of health insurance and increasing dependence on the private health sector have impoverished the poor and the marginalised, especially the scheduled tribe population. This study examines caste-based inequalities in households' out-of-pocket health expenditure in the south Indian state of Kerala and provides evidence on the consequent financial burden inflicted upon households in different caste groups.
Methods
Using data from a 2003-2004 panel survey in Kottathara Panchayat that collected detailed information on health care consumption from 543 households, we analysed inequality in per capita out-of-pocket health expenditure across castes by considering households' health care needs and types of care utilised. We used multivariate regression to measure the caste-based inequality in health expenditure. To assess health expenditure burden, we analysed households incurring high health expenses and their sources of finance for meeting health expenses.
Results
The per capita health expenditures reported by four caste groups accord with their status in the caste hierarchy. This was confirmed by multivariate analysis after controlling for health care needs and influential confounders. Households with high health care needs are more disadvantaged in terms of spending on health care. Households with high health care needs are generally at higher risk of spending heavily on health care. Hospitalisation expenditure was found to have the most impoverishing impacts, especially on backward caste households.
Conclusion
Caste-based inequality in household health expenditure reflects unequal access to quality health care by different caste groups. Households with high health care needs and chronic health care needs are most affected by this inequality. Households in the most marginalised castes and with high health care need require protection against impoverishing health expenditures. Special emphasis must be given to funding hospitalisation, as this expenditure puts households most at risk in terms of mobilising monetary resources. However, designing protection instruments requires deeper understanding of how the uncovered financial burden of out-patient and hospitalisation expenditure creates negative consequences and of the relative magnitude of this burden on households.
doi:10.1186/1475-9276-10-1
PMCID: PMC3024220  PMID: 21214941
15.  Prevalence of coronary artery disease and coronary risk factors in Kerala, South India: A population survey – Design and methods 
Indian Heart Journal  2013;65(3):243-249.
Background
There is paucity of reliable contemporary data on prevalence of coronary artery disease (CAD) and risk factors in Indians. Only a few studies on prevalence of CAD have been conducted in Kerala, a Southern Indian state. The main objective of the Cardiological Society of India Kerala Chapter Coronary Artery Disease and Its Risk Factors Prevalence Study (CSI Kerala CRP Study) was to determine the prevalence of CAD and risk factors of CAD in men and women aged 20–79 years in urban and rural settings of three geographical areas of Kerala.
Methods
The design of the study was cross-sectional population survey. We estimated the sample size based on an anticipated prevalence of 7.4% of CAD for rural and 11% for urban Kerala. The derived sample sizes for rural and urban areas were 3000 and 2400, respectively. The urban areas for sampling constituted one ward each from three municipal corporations at different parts of the state. The rural sample was drawn from two panchayats each in the same districts as the urban sample. One adult from each household in the age group of 20–59 years was selected using Kish method. All subjects between 60 and 79 years were included from each household. A detailed questionnaire was administered to assess the risk factors, history of CAD, family history, educational status, socioeconomic status, dietary habits, physical activity and treatment for CAD; anthropometric measurements, blood pressure, electrocardiogram and fasting blood levels of glucose and lipids were recorded.
doi:10.1016/j.ihj.2013.04.008
PMCID: PMC3861304  PMID: 23809375
Population survey; Coronary artery disease; Coronary risk factors; Kerala
16.  A Population Based Case Control Study on Breast Cancer and the Associated Risk Factors in a Rural Setting in Kerala, Southern India 
Introduction: The incidence of breast cancer is increasing in developing countries over three decades. Despite good health indicators breast cancer is a public health problem in Kerala with an annual incidence of 14.9/100000 population. Identifying the risk factors helps to reduce the incidence in future.
Method: A Population based case control study was conducted among all the breast cancer cases in the Arpookara Panchayat of Kottayam district in Kerala. 20 cases of breast cancer were paired with age matched controls from the same geographic area (ratio 1:4) with a total of 100 study participants. Data were collected by interviewing the participants using a pre tested structured questionnaire.
Analysis was done by the authors using SPSS version 16.0
Results: Age group of participants ranged from 32-70 years with mean age of 49.7 + 10.39. Early menarche < 13 years [Odds Ratio =3.2, p= 0.03], being unmarried and single, family history of breast cancer [Odds Ratio = 3.5, p = 0.02], previous history of benign breast tumours [Odds Ratio =8.14, p= 0.04], breast feeding less than 2 years [Odds Ratio = 2.28, p = 0.01 ] were found to be the risk factors for the breast cancer and the birth of first child before 30 years [Odds Ratio =0.302, p = 0.03 ] was found to be a protective factor for breast cancer. 60% of cases belonged to lower socioeconomic status [Odds Ratio = 14.47, p = 0.03]. Despite high literacy status, significantly lower awareness about symptoms of breast cancer and self examination of the breast were noted [Odds Ratio =11.6, p= 0.03].
Conclusion: Awareness about symptoms of breast cancer and self examination of the breast were lacking in the study population. Health care personnel should be trained to spread the awareness of breast cancer in the community and to identify the vulnerable groups at the primary care settings itself. The policy makers can consider encouraging community participation by involving the non-governmental organizations, women self help groups and Public Private Partnerships in spreading the awareness of breast cancer.
doi:10.7860/JCDR/2013/5830.3356
PMCID: PMC3809635  PMID: 24179896
Arpookara Panchayat; Kottayam; Case control study; Odds ratio
17.  Prevalence and correlates of self-reported state of teeth among schoolchildren in Kerala, India 
BMC Oral Health  2006;6:10.
Background
Oral health status in India is traditionally evaluated using clinical indices. There is growing interest to know how subjective measures relate to outcomes of oral health. The aims of the study were to assess the prevalence and correlates of self-reported state of teeth in 12-year-old schoolchildren in Kerala, India.
Methods
Cross-sectional survey data were used. The sample consisted of 838 12-year-old schoolchildren. Data was collected using clinical examination and questionnaire. The clinical oral health status was recorded using Decayed, Missing and Filled Teeth (DMFT) and Oral Hygiene Index – Simplified (OHI-S). The questionnaire included questions on sociodemographics, self reports of behaviour, knowledge and oral problems and a single-item measuring self-reported state and satisfaction with appearance of teeth. The Kappa values for test-retest of the questionnaire ranged from 0.55 to 0.97.
Results
Twenty-three per cent of the schoolchildren reported the state of teeth as bad. Multivariate logistic regression showed significant associations between schoolchildren who reported to have bad teeth and poor school performance (Odds Ratio (OR) = 2.5), having bad breath (OR = 2.4), food impaction (OR = 1.7) dental visits (OR = 1.6), being dissatisfied with appearance of teeth (OR = 4.2) and caries experience (OR = 1.7). The explained variance was highest when the variables dental visits, bleeding gums, bad breath, food impaction and satisfaction with appearance were introduced into the model (19%).
Conclusion
A quarter of 12-year-olds reported having bad teeth. The self-reported bad state of teeth was associated with poor school performance, having bad breath and food impaction, having visited a dentist, being dissatisfied with teeth appearance and having caries experience. Information from self-reports of children might help in planning effective strategies to promote oral health.
doi:10.1186/1472-6831-6-10
PMCID: PMC1559687  PMID: 16817952
18.  The Group-lending Model and Social Closure: Microcredit, Exclusion, and Health in Bangladesh 
According to social exclusion theory, health risks are positively associated with involuntary social, economic, political and cultural exclusion from society. In this paper, a social exclusion framework has been used, and available literature on microcredit in Bangladesh has been reviewed to explore the available evidence on associations among microcredit, exclusion, and health outcomes. The paper addresses the question of whether participation in group-lending reduces health inequities through promoting social inclusion. The group-lending model of microcredit is a development intervention in which small-scale credit for income-generation activities is provided to groups of individuals who do not have material collateral. The paper outlines four pathways through which microcredit can affect health status: financing care in the event of health emergencies; financing health inputs such as improved nutrition; as a platform for health education; and by increasing social capital through group meetings and mutual support. For many participants, the group-lending model of microcredit can mitigate exclusionary processes and lead to improvements in health for some; for others, it can worsen exclusionary processes which contribute to health disadvantage.
PMCID: PMC2928107  PMID: 19761085
Exclusion; Economic assistance; Health status; Group-lending model; Health equity; Microcredit; Social exclusion; Bangladesh
19.  Study of menopausal symptoms, and perceptions about menopause among women at a rural community in Kerala 
Journal of Mid-Life Health  2013;4(3):182-187.
Background:
Menopausal health demands priority in Indian scenario due to increase in life expectancy and growing population of menopausal women. Most are either unaware or do not pay adequate attention to these symptoms.
Aims:
To find the prevalence of menopausal symptoms and perceptions regarding menopause among menopausal women of Kerala.
Settings and Design:
A community based cross-sectional house to house survey was conducted at Anjarakandy a field practice area under Kannur Medical College, Anjarakandy.
Materials and Methods:
The study was conducted among 106 postmenopausal women staying more than 6 months at Anjarakandy with the help of pretested questionnaire administered by a trained social worker from January to October 2009. Before that a pilot study was conducted and required sample size of 100 was calculated. Random sampling of houses was done.
Statistical Analysis:
Data was coded, entered, and analyzed using SPSS 15. Chi-square test, proportions, and percentages were used.
Results:
The mean age of attaining menopause was 48.26 years. Prevalence of symptoms among ladies were emotional problems (crying spells, depression, irritability) 90.7%, headache 72.9%, lethargy 65.4%, dysuria 58.9%, forgetfulness 57%, musculoskeletal problems (joint pain, muscle pain) 53.3%, sexual problems (decreased libido, dyspareunia) 31.8%, genital problems (itching, vaginal dryness) 9.3%, and changes in voice 8.4%. Only 22.4% of women knew the correct cause of menopause.
Conclusions:
Thus study stated that all the ladies were suffering from one or more number of menopausal symptoms. Ladies should be made aware of these symptoms, their causes and treatment respectively.
doi:10.4103/0976-7800.118997
PMCID: PMC3952411  PMID: 24672192
Kerala; menopause; rural; survey
20.  Prevalence of Child Marriage and its Impact on the Fertility and Fertility Control Behaviors of Young Women in India 
Lancet  2009;373(9678):1883-1889.
Objectives
Child marriage in India is considered a major barrier to the nation's social and economic development, as well as a major women's health concern. The current study assesses prevalence of child marriage (i.e., marriage prior to the national legal age of 18 years) among young adult women in India, and associations between child marriage and women's fertility and fertility control behaviors.
Study Design
Cross-sectional analyses of a nationally representative household sample of Indian women ages 16-49 years (N=124,385) collected in 2005-2006 via the National Family Health Survey-3.
Participants
Analyses were restricted to women age 20-24 years (n=22,807) and the subsample of ever married women aged 20-24 years (n=14,628).
Data Analysis
Prevalence estimates of child marriage were produced for all women 20-24 years. Using the ever married subsample, simple regression models, models adjusted for demographics, and models adjusted for demographics and duration of marriage were constructed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between child marriage and both fertility and fertility control outcomes.
Fertility and Fertility Control Outcomes
No contraception prior to childbirth, childbirth within first year of marriage, high fertility (3 or more births), history of recent rapid repeat childbirth, unwanted pregnancy, and female sterilization.
Results
Child marriage was reported by 44.5% of Indian women ages 20-24 years; 22.6% reported marriage prior to age 16 years, and 2.6% were married prior to age 13 years. Child marriage was significantly associated with women's increased risk for no contraceptive use prior to first childbirth (AOR=1.37, 95% CI=1.22, 1.54), high fertility (AOR=7.40, 95% CI=6.45, 8.50), history of rapid repeat childbirth (AOR=3.00, 95% CI=2.74, 3.29), multiple unwanted pregnancies (AOR=2.36, 95% CI=1.90, 2.94), pregnancy termination (AOR=1.22; 95% CI=1.06, 1.41) and female sterilization (AOR=5.54, 95% CI=4.86, 6.32) relative to women married at 18 years or older. Associations between child marriage and rapid repeat childbirth, multiple unwanted pregnancies, pregnancy termination and sterilization remained significant after controlling for duration of marriage.
Conclusions
Child marriage remains pervasive in India and is linked to high and less controlled fertility, as well as increased likelihood of termination and sterilization by young adulthood. While greater enforcement of existing policies are critical to preventing child marriage, education and support services regarding family planning for adolescent wives and their families are also clearly indicated in order to reduce the reproductive health consequences of this socially normative practice.
doi:10.1016/S0140-6736(09)60246-4
PMCID: PMC2759702  PMID: 19278721
child marriage; family planning; India
21.  Domestic and Environmental Factors of Chikungunya-affected Families in Thiruvananthapuram (Rural) District of Kerala, India 
Background:
The world is experiencing a pandemic of chikungunya which has swept across Indian Ocean and the Indian subcontinent. Kerala the southernmost state of India was affected by the chikungunya epidemic twice, first in 2006 and then in 2007. Kerala has got geography and climate which are highly favorable for the breeding of Aedes albopictus, the suspected vector.
Aim:
The aim of the study was to highlight the various domestic and environmental factors of the families affected by chikungunya in 2007 in Thiruvananthapuram district (rural) of Kerala. Settings and design:This is a cross-sectional survey conducted in Thiruvananthapuram (rural) district during November 2007.
Settings and design:
This is a cross-sectional survey conducted in Thiruvananthapuram (rural) district during November 2007
Materials and Methods:
Samples were selected from field area under three Primary Health Centers.These areas represent the three terrains of the district namely the highland, midland, and lowland. The sample size was estimated to be 134 houses from each study area.The field area of health workers was selected as clusters and six subcenters from each primary health center were randomly selected (lot method).
Results and Conclusions:
The proportion of population affected by chikungunya fever is 39.9% (38.9-40.9%). The investigators observed water holding containers in the peri-domestic area of 95.6% of the houses. According to regression (binary logistic) analysis, the area of residence [adjusted odds ratio (OR) = 8.01 (6.06-14.60)], residing in a non-remote area [adjusted OR=0.25 (0.16-0.38)], perceived mosquito menace [adjusted OR=3.07 (2.31-4.64)], and containers/tires outside the house [adjusted OR=5.61 (2.74-27.58)] were the independent predictors of the occurrence of chikungunya in households.
doi:10.4103/0974-777X.77293
PMCID: PMC3068575  PMID: 21572606
Chikungunya; Domestic factors; Environmental factors; Kerala
22.  Self-reported health status and access to health services in a sample of prisoners in Italy 
BMC Public Health  2011;11:529.
Background
Self-reported health status in underserved population of prisoners has not been extensively explored. The purposes of this cross-sectional study were to assess self-reported health, quality of life, and access to health services in a sample of male prisoners of Italy.
Methods
A total of 908 prisoners received a self-administered anonymous questionnaire pertaining on demographic and detention characteristics, self-reported health status and quality of life, access to health services, lifestyles, and participation to preventive, social, and rehabilitation programs. A total of 650 prisoners agreed to participate in the study and returned the questionnaire.
Results
Respectively, 31.6% and 43.5% of prisoners reported a poor perceived health status and a poor quality of life, and 60% admitted that their health was worsened or greatly worsened during the prison stay. Older age, lower education, psychiatric disorders, self-reported health problems on prison entry, and suicide attempts within prison were significantly associated with a perceived worse health status. At the time of the questionnaire delivery, 30% of the prisoners self-reported a health problem present on prison entry and 82% present at the time of the survey. Most frequently reported health problems included dental health problems, arthritis or joint pain, eye problems, gastrointestinal diseases, emotional problems, and high blood pressure. On average, prisoners encountered general practitioners six times during the previous year, and the frequency of medical encounters was significantly associated with older age, sentenced prisoners, psychiatric disorders, and self-reported health problems on prison entry.
Conclusions
The findings suggest that prisoners have a perceived poor health status, specific care needs and health promotion programs are seldom offered. Programs for correction of risk behaviour and prevention of long-term effects of incarceration on prisoners' health are strongly needed.
doi:10.1186/1471-2458-11-529
PMCID: PMC3151234  PMID: 21726446
23.  Experiences of Junior Public Health Nurses in Delivery of Maternal Healthcare Services to Tribal Women in Kerala 
Background:
The maternal health care indicators are better in Kerala even in the tribal districts than the national averages. The tribal population scattered in hilly areas or other difficult terrains heavily constraints the MPHW female (Junior Public Health Nurse in Kerala) from providing services. The study was intended to describe the experiences of the Junior Public Health Nurses (JPHN) in delivery of maternal health care services to tribal women in Kerala.
Materials and Methods:
JPHNs posted in Thariode panchayat under the sub centers of CHC Thariode in Wayanad district of Kerala. This is a Qualitative study with in-depth interview of the JPHNs using an interview guide.
Results and Inferences:
The various difficulties experienced by JPHNs in delivering the services in tribal areas were lack of sufficient time for field work, travel difficulties faced due to the hilly terrain and lack of public transport facilities, more time spent on travel than actual time spent for field work, cultural and language barriers and extra inputs put up in service delivery to tribal women.
Conclusion and Recommendations:
The JPHNs serving in tribal areas overcame various constraints in service delivery like hilly terrain, limited public transport facilities, long hours spent in travelling, cultural and language barriers by putting in extra effort, time and personal money to fulfill their responsibilities. It is suggested that the JPHNs be given compensatory off to complete records and extra remuneration to cover their out of pocket expenditure on travelling to difficult areas.
doi:10.4103/2249-4863.109948
PMCID: PMC3894011  PMID: 24479046
Difficulties; maternal health; multi purpose health worker female; tribal areas
24.  Group Interventions were not Effective for Female Turkish Migrants with Recurrent Depression – Recommendations from a Randomized Controlled Study 
Social behavior and personality  2011;39(9):1217-1234.
We tested group interventions for women with a Turkish migration background living in Austria and suffering from recurrent depression. N = 66 participants were randomized to: (1) Self-Help Groups (SHG), (2) Cognitive Behavior Therapy (CBT) Groups, and (3) a Wait-List (WL) Control condition. Neither SHG nor CBT were superior to WL. On an individual basis, about one third of the participants showed significant improvements with respect to symptoms of depression. Younger women, women with a longer duration of stay in Austria and those who had encountered a higher number of traumatic experiences, showed increased improvement of depressive symptoms. The results suggest that individual treatment by ethnic, female psychotherapists should be preferred to group interventions.
PMCID: PMC3184506  PMID: 21976784
Self-Help Group; group therapy; acculturation; migration; depression
25.  Are self-reports of health and morbidities in developing countries misleading? Evidence from India 
Social science & medicine (1982)  2008;68(2):260-265.
Self reported measures of poor health and morbidities from developing countries tend to be viewed with considerable skepticism. Examination of the social gradient in self-reported health and morbidity measures provides a useful test of the validity of self-reports of poor-health and morbidities. The prevailing view, in part influenced by Amartya Sen, is that socially disadvantaged individuals will fail to perceive and report the presence of illness or health-deficits because an individual’s assessment of their health is directly contingent on their social experience. In this study, we tested whether the association between self-reported poor-health/morbidities and socioeconomic status (SES) in India follows the expected direction or not. Cross sectional logistic regression analyses were carried out on a nationally representative population based sample from the 1998–99 Indian National Family Health Survey (INFHS); and 1995–96 and 2004 Indian National Sample Survey (INSS). Four binary outcomes were analyzed: any self-reported morbidity; self-reported sickness in the last 15 days; self-reported sickness in the past year; and poor self-rated health. In separate adjusted models, individuals with no education reported higher levels of any self-reported, self-reported sickness in the last 15 days, self-reported sickness in the last year, and poor self-rated health compared to those with most education. Contrary to the prevailing thesis, we find that the use of self-rated ill health has face validity as assessed via its relationship to SES. A less dismissive and pessimistic view of health data obtained through self-reports seems warranted.
doi:10.1016/j.socscimed.2008.10.017
PMCID: PMC2652643  PMID: 19019521
Validity; India; Subjective health; Socioeconomic Status (SES); morbidity

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