P.S. Sarma

Risk factors for acute ischaemic stroke in young adults in South India

Background: Stroke is a leading cause of death and disability in developing countries, afflicting individuals at a young age. The contribution of established vascular risk factors to ischaemic stroke in young adults has not been evaluated systematically in Indians. Methods: We conducted a case control study in 214 South Indian patients with first acute ischaemic stroke that occurred between the ages of 15 and 45 years, 99 age and sex matched hospital controls and 96 community controls. We compared the prevalence of the following risk factors: smoking, elevated blood pressure, high fasting blood glucose and abnormal lipids. Results: Compared with community controls, stroke patients had a higher prevalence of smoking (multivariable adjusted odds ratio (OR) 7.77, 95% CI 1.93 to 31.27), higher systolic blood pressure (OR per SD increment of 1.88, 95% CI 1.01 to 3.49) and fasting blood glucose (OR per SD increment of 4.55, 95% CI 1.63 to 12.67), but lower high density lipoprotein (HDL) cholesterol (OR per SD increment of 0.17, 95% CI 0.09 to 0.30). Compared with hospital controls, stroke patients had a higher prevalence of smoking (OR 3.95, 95% CI 1.61 to 9.71) and lower HDL cholesterol (OR per SD increment 0.27, 95% CI 0.17 to 0.44). The presence of ⩾3 metabolic syndrome components was associated strongly with stroke (OR 4.76, 95% CI 1.93 to 11.76; OR 2.09, 95% CI 1.06 to 4.13) compared with community and hospital controls. Conclusions: Key components of the metabolic syndrome and smoking are associated with ischaemic stroke in young South Indian adults. Our observations underscore the importance of targeting adolescents and young adults for screening and prevention to reduce the burden of ischaemic stroke in young adults.

Incidence of hypertension and its risk factors in rural Kerala, India: A community-based cohort study

OBJECTIVESnTo investigate the incidence of hypertension and its risk factors in Kerala, India where the epidemiological transition is more advanced than elsewhere in India.nnnSTUDY DESIGNnProspective cohort study.nnnMETHODSnA sample of 297 individuals (aged 15-64 years) in rural Kerala, India, who were free of hypertension at study enrolment, were followed-up from 2003 to 2010. At enrolment, demographic characteristics and behavioural risk factors were determined by interview, and the participants underwent physical (blood pressure, height, weight and waist circumference) and biochemical examinations (fasting plasma glucose and serum lipids). At follow-up, blood pressure readings were repeated using the original tool following the same protocol.nnnRESULTSnNearly one-quarter (23.6%) of the sample developed hypertension over a mean follow-up period of 7.1 (standard deviation 0.2) years. Age ≥35 years [relative risk (RR) 4.00, 95% confidence interval (CI) 2.37-6.03], current smoking [RR 1.99, 95% CI 1.14-2.97, population-attributable risk percent (PAR%) 13.3%], high-normal blood pressure (RR 3.53 vs optimal blood pressure, 95% CI 2.17-5.28, PAR% 44.0%) and central obesity (RR 2.45, 95% CI 1.45-3.70, PAR% 40.4%) were significantly associated with incident hypertension. Collectively, current smoking, high-normal blood pressure and central obesity accounted for 70.1% of all new cases of hypertension. Awareness, treatment and control rates of incident hypertension were 42.9%, 22.9% and 11.4%, respectively.nnnCONCLUSIONSnThis rural sample showed a high incidence of hypertension. This underscores the need for primary prevention of hypertension through lifestyle modification strategies targeting individuals with high-normal blood pressure, central obesity and current smoking. The healthcare system needs to improve the level of awareness, treatment and control of hypertension in this population.

Smoking cessation among diabetes patients: results of a pilot randomized controlled trial in Kerala, India

BackgroundIndia has the second largest diabetic population (61 million) and tobacco users (275 million) in the world. Data on smoking cessation among diabetic patients are limited in low and middle income countries. The objective of the study was to document the effectiveness of diabetic specific smoking cessation counseling by a non-doctor health professional in addition to a cessation advice to quit, delivered by doctors.MethodsIn our parallel-group randomized controlled trial, we selected 224 adult diabetes patients aged 18 years or older who smoked in the last month, from two diabetes clinics in South India. Using a computer generated random sequence with block size four; the patients were randomized equally into intervention-1 and intervention-2 groups. Patients in both groups were asked and advised to quit smoking by a doctor and distributed diabetes specific education materials. The intervention-2 group received an additional diabetes specific 30 minutes counseling session using the 5As (Ask, Advise, Assess, Assist and Arrange), and 5 Rs (Relevance, Risks, Rewards, Roadblocks and Repetition) from a non-doctor health professional. Follow up data were available for 87.5% of patients at six months. The Quit Tobacco International Project is supported by a grant from the Fogarty International Centre of the US National Institutes of Health (RO1TW005969-01).The primary outcomes were quit rate (seven day smoking abstinence) and harm reduction (reduction of the number of cigarettes / bidis smoked per day > 50% of baseline use) at six months.ResultsIn the intention to treat analysis, the odds for quitting was 8.4 [95% confidence interval (CI): 4.1-17.1] for intervention-2 group compared to intervention-1 group. Even among high level smokers the odds of quitting was similar. The odds of harm reduction was 1.9 (CI: 0.8-4.1) for intervention-2 group compared to intervention-1 group.ConclusionsThe value addition of culturally sensitive diabetic specific cessation counseling sessions delivered by non-doctor health professional was an impressive and efficacious way of preventing smoking related diabetic complications.Trial RegistrationClinical Trial Registry of India (CTRI/2012/01/002327)

Awareness, attitude and perceived barriers regarding implementation of the Cigarettes and Other Tobacco Products Act in Assam, India.

BACKGROUNDnTobacco use is a major public health problem in India. The Cigarettes and Other Tobacco Products Act (COTPA) was developed to curb this epidemic. Because no study has been conducted on the awareness, attitude and perceived barriers regarding the implementation of COTPA, this study was undertaken.nnnMATERIALS AND METHODSnA community-based cross-sectional survey was conducted among 300 adults (mean age 41 years, 52% men) selected by cluster sampling method from Guwahati Municipal Corporation. Information on awareness, attitude and their predictors and barriers for implementation was collected using a pretested, structured interview schedule. Multivariate analysis was done using SPSS.nnnRESULTSnAdults older than 50 years were 3 times (odds ratio [OR] 3.02, 95% CI 1.44-6.31) and those with more than 10 years of schooling were 4 times (OR 3.60, 95% CI 1.70-7.70) more likely to have good awareness of COTPA compared with their counter parts. Those belonging to the middle socioeconomic status (SES) were 3 times (OR 3.36, 95% CI 1.13-10.01), those who reported secondhand smoking harmful were 3 times (OR 3.32, 95% CI 1.45-7.62), and those with more than 10 years of schooling were 3 times (OR 2.92, 95% CI 1.01-8.45) more likely to have positive attitude toward COTPA compared with their counterparts. Lack of complete information and awareness of the Act, public opposition, cultural acceptance of tobacco use, lack of political support, and less priority for tobacco control were reported as barriers for COTPA implementation.nnnCONCLUSIONnEfforts should be made to increase the awareness of COTPA focusing on younger population, less educated, and those belonging to the low SES.

Design and methodology of a community-based cluster-randomized controlled trial for dietary behaviour change in rural Kerala

Background Interventions targeting lifestyle-related risk factors and non-communicable diseases have contributed to the mainstream knowledge necessary for action. However, there are gaps in how this knowledge can be translated for practical day-to-day use in complex multicultural settings like that in India. Here, we describe the design of the Behavioural Intervention for Diet study, which was developed as a community-based intervention to change dietary behaviour among middle-income households in rural Kerala. Methods This was a cluster-randomized controlled trial to assess the effectiveness of a sequential stage-matched intervention to bring about dietary behaviour change by targeting the procurement and consumption of five dietary components: fruits, vegetables, salt, sugar, and oil. Following a step-wise process of pairing and exclusion of outliers, six out of 22 administrative units in the northern part of Trivandrum district, Kerala state were randomly selected and allocated to intervention or control arms. Trained community volunteers carried out the data collection and intervention delivery. An innovative tool was developed to assess household readiness-to-change, and a household measurement kit and easy formulas were introduced to facilitate the practical side of behaviour change. The 1-year intervention included a household component with sequential stage-matched intervention strategies at 0, 6, and 12 months along with counselling sessions, telephonic reminders, and home visits and a community component with general awareness sessions in the intervention arm. Households in the control arm received information on recommended levels of intake of the five dietary components and general dietary information leaflets. Discussion Formative research provided the knowledge to contextualise the design of the study in accordance with socio-cultural aspects, felt needs of the community, and the ground realities associated with existing dietary procurement, preparation, and consumption patterns. The study also addressed two key issues, namely the central role of the household as the decision unit and the long-term sustainability through the use of existing local and administrative networks and community volunteers.Background Interventions targeting lifestyle-related risk factors and non-communicable diseases have contributed to the mainstream knowledge necessary for action. However, there are gaps in how this knowledge can be translated for practical day-to-day use in complex multicultural settings like that in India. Here, we describe the design of the Behavioural Intervention for Diet study, which was developed as a community-based intervention to change dietary behaviour among middle-income households in rural Kerala. Methods This was a cluster-randomized controlled trial to assess the effectiveness of a sequential stage-matched intervention to bring about dietary behaviour change by targeting the procurement and consumption of five dietary components: fruits, vegetables, salt, sugar, and oil. Following a step-wise process of pairing and exclusion of outliers, six out of 22 administrative units in the northern part of Trivandrum district, Kerala state were randomly selected and allocated to intervention or control arms. Trained community volunteers carried out the data collection and intervention delivery. An innovative tool was developed to assess household readiness-to-change, and a household measurement kit and easy formulas were introduced to facilitate the practical side of behaviour change. The 1-year intervention included a household component with sequential stage-matched intervention strategies at 0, 6, and 12 months along with counselling sessions, telephonic reminders, and home visits and a community component with general awareness sessions in the intervention arm. Households in the control arm received information on recommended levels of intake of the five dietary components and general dietary information leaflets. Discussion Formative research provided the knowledge to contextualise the design of the study in accordance with socio-cultural aspects, felt needs of the community, and the ground realities associated with existing dietary procurement, preparation, and consumption patterns. The study also addressed two key issues, namely the central role of the household as the decision unit and the long-term sustainability through the use of existing local and administrative networks and community volunteers.

Smoking Cessation Among Diabetic Patients in Kerala, India: 1-Year Follow-up Results From a Pilot Randomized Controlled Trial

Considering the adverse health effects of smoking, the American Diabetes Association recommends smoking cessation among diabetic patients (1). One-year follow-up data on smoking cessation among diabetic patients are not available (2). We conducted this study to find the effectiveness of diabetes-specific smoking cessation counseling by a nondoctor health professional (NDHP) in addition to quitting advice by a doctor at 1 year. We recruited 224 adult male diabetic patients aged ≥18 years who smoked in the previous month from two diabetes clinics of Kerala for our randomized controlled trial. They were randomized into two equal groups: intervention-1 and intervention-2. Patients in both groups were asked and advised by a doctor to quit smoking and education materials on smoking-related complications were provided. The intervention-2 group received four additional diabetes-specific 30-min smoking cessation counseling sessions at baseline and 1, 3, and 6 months …

Impact of a community based intervention program on awareness, treatment and control of hypertension in a rural Panchayat, Kerala, India.

OBJECTIVEnCommunity based intervention to control hypertension is extremely limited in India. We conducted this study to find the effectiveness of a community based intervention program on the awareness, treatment and control of hypertension.nnnMETHODSnA baseline survey was conducted among 4627 adults aged ≥30 years (men 44%) selected by cluster sampling. Information was collected using a structured interview schedule by trained local volunteers. They measured weight, height, waist circumference and blood pressure using standard protocol. The volunteers monitored blood pressure at least once a month and educated the people in neighborhood groups on the need for regular medication and reducing risk factors of hypertension for a period of six years. A post intervention survey was conducted among 2263 adults aged ≥30 years (men 49%). Stepwise logistic regression analysis was done to find the odds of change in awareness, treatment and control of hypertension.nnnRESULTSnThe odds of awareness (OR 4.18, 95% CI 3.44-5.08), treatment (OR 3.44 CI 2.81-4.22) and control (OR 4.39 CI 3.36-5.73) of hypertension increased significantly in the post intervention survey compared to the baseline survey. Baseline hypertension prevalence of 34.9% (CI 33.8-36.1) was reduced to 31.0% (CI 29.1-32.9) in the post intervention survey based on age adjusted analysis.nnnCONCLUSIONnOur community based intervention using trained community based volunteers could increase awareness, treatment and control of hypertension among adult hypertensives.

Adapting and Validating the Global Physical Activity Questionnaire (GPAQ) for Trivandrum, India, 2013

Introduction A limitation of the Global Physical Activity Questionnaire (GPAQ) in assessing physical activity in India is that it does not capture the diversity of activities across cultures and by sex. The purpose of this study was to culturally adapt and validate the GPAQ by using an accelerometer in Thiruvananthapuram City, India. Methods We developed a modified version of the GPAQ by adding a physical activity chart specific to the locale. We identified local physical activities through in-depth interviews, group discussions, and observation, and used Actigraph GT3X accelerometers to validate the modified GPAQ for a subsample of 47 women. Participants were drawn from a cross-sectional survey of 1,303 women aged 18 to 64 years, selected by multistage cluster sampling. Spearman rank correlation coefficients and intraclass correlation coefficients (ICC) were calculated to determine the correlation and level of agreement in moderate-to-vigorous physical activity (MVPA) on the basis of accelerometer measurement and the modified GPAQ. Results The correlation for MVPA between the modified GPAQ (overall) and the accelerometer (non-bouted MVPA) was 0.69 (95% confidence interval [CI], 0.39–0.85) with a moderately high ICC of 0.78 (95% CI, 0.56–0.90). The correlation for MVPA between the modified GPAQ and the accelerometer-based MVPA within bouts of at least 10 minutes was 0.60 (95% CI, 0.26–0.80) with an ICC of 0.55 (95% CI, 0.20–0.77) indicating a moderate level of agreement. Conclusion The GPAQ can be used for assessing physical activity among women in India, and its adaptation and validation may be useful in other low-income or middle-income countries where activities are diverse in type and intensity.

Development of a Tool to Stage Households' Readiness to Change Dietary Behaviours in Kerala, India.

Dietary interventions and existing health behaviour theories are centred on individuals; therefore, none of the available tools are applicable to households for changing dietary behaviour. The objective of this pilot study was to develop a practical tool that could be administered by community volunteers to stage households in rural Kerala based on readiness to change dietary behaviour. Such a staging tool, comprising a questionnaire and its algorithm, focusing five dietary components (fruits, vegetables, salt, sugar and oil) and households (rather than individuals), was finalised through three consecutive pilot validation sessions, conducted over a four-month period. Each revised version was tested with a total of 80 households (n = 30, 35 and 15 respectively in the three sessions). The tool and its comparator, Motivational Interviewing (MI), assessed the stage-of-change for a household pertaining to their: 1) fruit and vegetable consumption behaviour; 2) salt, sugar and oil consumption behaviour; 3) overall readiness to change. The level of agreement between the two was tested using Kappa statistics to assess concurrent validity. A value of 0.7 or above was considered as good agreement. The final version was found to have good face and content validity, and also a high level of agreement with MI (87%; weighted kappa statistic: 0.85). Internal consistency testing was performed using Cronbach’s Alpha, with a value between 0.80 and 0.90 considered to be good. The instrument had good correlation between the items in each section (Cronbach’s Alpha: 0.84 (fruit and vegetables), 0.85 (salt, sugar and oil) and 0.83 (Overall)). Pre-contemplation was the most difficult stage to identify; for which efficacy and perceived cooperation at the household level were important. To the best of our knowledge, this is the first staging tool for households. This tool represents a new concept in community-based dietary interventions. The tool can be easily administered by lay community workers and can therefore be used in large population-based studies. A more robust validation process with a larger sample is needed before it can be widely used.