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Available online at: www.ijmrhs.com DOI: 10.5958/2319-5886.2015.00144.7
Research article Open Access
HIV/AIDS KNOWLEDGE AND PATTERNS OF SEXUAL BEHAVIOR AMONG ADULT
SLUM DWELLERS IN MUMBAI, INDIA
Saba Syed1, Sukhdas Gangam
2
INTRODUCTION
HIV/AIDS was first identified in India in 1986[1]
when
serological testing found that 10 of 102 female sexworkers in Chennai were HIV positive. In the face of
increasing numbers of people being identified with HIV,
the Government of India (GOI) established the National
AIDS Committee (NAC) and in 1992, the National AIDS
Control Organization (NACO).[1]
In India, currently 2.1
million people are living with HIV.[2]
The four high
prevalence states Andhra Pradesh, Maharashtra,
Karnataka, Tamil Nadu account for 55% of all HIV
infections in the country[3]
In National AIDS Control Programme (NACP IV);
prevention is the mainstay of the strategic response to
HIV/AIDS in India as 99% population of the country is
uninfected; prevention strategies include expanding IEC
services for (a) general population and (b) high risk groups
with a focus on behaviour change and demand
generation. Among the general population, women, youth
and adolescents are seen as most vulnerable. Also, lack
of access to correct information can pose a possible
barrier in HIV/AIDS prevention programmes. Interventions
for general population are about raising their awareness of
HIV. Awareness raising brings behaviour change.
Changing knowledge, attitudes and behaviour as a
prevention strategy of HIV/AIDS thus is a key thrust area
of the National AIDS Control Programme. Through this
route the programme aims to reach out to 80 percent of the high risk groups and 95 percent of the young people.[4]
In metropolitan cities; the rising rate of urbanization and
the accompanying disproportionate growth in theproportion of poor city residents pose new challenges for
health care in urban slums. They may start sexual
intercourse at earlier ages, have more sexual partners,
and are less likely than other city residents to know of or
adopt preventive measures against contracting Sexually
Transmitted Infections/Reproductive Tract Infections
STIs/RTIs and HIV/AIDS[5]
. Mumbai, the most populous
city in India is unique in having a huge migrant population;
largely young as it offers opportunities for all to earn a
living. Slums too are a ubiquitous feature of Mumbai’s
geographical landscape. Socio-economic determinants
that make a person vulnerable also increase the risk of
exposure to HIV. People inhabiting slums have low
awareness and are more vulnerable to RTI/STIs and
HIV/AIDS[5]
. As HIV infection is entirely preventable
through awareness raising about its occurrence and
spread, it is very significant in protecting the people from
the epidemic. Thus, the present study was planned to
assess HIV/AIDS knowledge and sexual behaviour,
reported symptoms of STI/RTI’s along with the socio
demographic profile of adult population of urban slum
dwellers. Information regarding age at first sexual
intercourse, reasons for not using condoms during
intercourse may give insights into novel approaches of
applying HIV/AIDS prevention strategies.
ARTICLE INFO
Received: 4th Apr 2015
Revised: 23rd May 2015
Accepted: 29th Jun 2015
Authors details: 1 Assistant Professor,
Department of Community Medicine,
Apollo Institute of Medical Sciences and
Research, Mumbai, Maharashtra, India2 Assosicate Professor, Department of
Community Medicine, Apollo Institute of
Medical Sciences and Research,
Mumbai, Maharashtra, India
Corresponding author: Saba Syed
Apollo Institute of Medical Sciences and
Research, Mumbai, Maharashtra, India
Mumbai, Maharashtra, India
Email: [email protected]
Keywords: HIV/AIDS Knowledge, Sexualbehaviour, Slum dwellers
ABSTRACT
Background: In India, currently 2.1 million people are living with HIV.
Prevention is the mainstay of the strategic response to HIV/AIDS in India.
Awareness rising brings behaviour change. People inhabiting slums have low
awareness and are more vulnerable to RTI/STIs and HIV/AIDS. Aims: To
assess HIV/AIDS knowledge, sexual behaviour, reported symptoms of
STI/RTI’s along with the socio demographic profile of adult population of
urban slum dwellers. Methods: A cross sectional, qualitative study. The study
area, chosen by convenience sampling was an urban slum located in M East
Ward of Greater Mumbai. The study was finally conducted with 104
participants. Results: The mean age of surveyed participants was 23.5yrs
and nearly 38(40%) of participants were illiterate Age at first sexualintercourse among the study participants was between 12-16 years for
23(22.10%) participants. Among study participants; 30(29%) of participants
do not have any knowledge about prevention and transmission of HIV/AIDS.
Conclusions: Urban slum residents in Mumbai have knowledge gap
regarding HIV/AIDS transmission and prevention. Initiation of sexual
intercourse is at an early age, a high percentage report symptoms of
STI/RTIs.
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MATERIAL AND METHODS
Study design: It was a cross sectional, qualitative study.
Ethical approval & Consent: Approval from institutional
ethics committee (IEC) was obtained prior to initiation of
the study. Informed verbal consent of the participants
was taken after explaining to them that the
information revealed by them would be kept strictly
confidential and those who gave consent were enrolled as
study participants
Mumbai is divided into administrative zones and wards.
The study area, chosen by convenience sampling was an
urban slum located in M East Ward of Greater Mumbai. It
has a population of approximately one lakh, which is
predominantly migrant. Inhabitants of the slum reside in
dwellings in multiple lanes, parallel to each other.
Sampling technique: By systematic random sampling
technique initially, ten lanes were selected by choosing
every fifth lane of the study area. All dwellings in the
selected lane were enlisted; following which every fifth
household was selected, until the number of study
participants equalled ten in each lane. Locked houseswere excluded and the next fifth house on the list was
selected.
Inclusion criteria: Individuals with chronological age
eighteen years and above; residing in these households
were eligible to be enrolled as study participants.
Sample size: Assuming HIV prevalence of between
0.25%- 0.3% in general population; the required sample
size was calculated to be 104 using formula [s=4 PQ/ E2].
Study was finally conducted with 104 participants.
Methodology
A self designed, semi- structured questionnaire was
prepared comprising questions pertaining to the
demographic and socioeconomic Profile, their knowledge
regarding HIV /AIDS prevention and transmission,
misconceptions regarding HIV/AIDS transmission. It also
included questions on age at first sexual intercourse,
reported symptoms of Sexually Transmitted Infections
(STIs) /Reproductive Tract Infections (RTIs) and means of
protection of themselves from an intimate partner who has
symptoms of STI/RTIs and their sexual Practices. All
participants reporting symptoms of STI/RTI were referred
to the nearest health care centre. Socioeconomic
classification of study participants was done using B. G
Prasad’s classification.[6]
A pilot study was carried out
prior to the final study with thirty participants to test theaccuracy and completeness of the questionnaire
Data collection was done by administration of the
questionnaire through personal interviews and in depth
discussions with the participants.
Statistical analysis: Data was collated and qualitative
data analysis (frequencies & percentages) done by using
MS Excel.
RESULTS
Table 1 depicts the demographic profile of study
participants. The mean age of study participants was
23.5yrs .Table 2 depicts knowledge regarding HIV/AIDS
prevention & transmission among study participants and
30(29%) of participants do not have any knowledge about
prevention and transmission of HIV/AIDS. Table 3 depicts
Misconceptions Regarding HIV/AIDS transmission. Table
4 shows Reported symptoms of STI/RTIs in study
participants.
Age at first sexual intercourse among the study
participants was between 12-16 years for 23(22.10%)
participants and between 17-21yrs for 62(59.60%)
participants whereas it was between 22-26 yrs for
14(13.50%) participants and in 4(3.84%) participants it
was between 27-31 yrs. Partner during first sexual
intercourse for 85(81.20%) participants was their spouse,
for 2(1.9%) it was an acquaintance, for 5(7.14%) male
participants it was a commercial sex worker, for 3(2.88%)
partner was a relative and for 8 (7.70%) male participants
it was their intimate partners. Regarding condom usage
during first sexual intercourse; only 3(2.90%) participants
had used a condom and 100(96.20%) had not used a
condom. Among the reasons for not using condoms,
9(8.70%) revealed they had no knowledge of how to use acondom, 6 (5.8%) revealed that a condom was not
available at that time, two revealed that they did not feel it
was required.
Regarding means of protection of themselves from an
intimate partner who has symptoms of STI/RTIs,
31(29.80%) said they would insist on condom usage is
preferable, 17(16.30%) said refusal for intercourse and
9(8.70%) participants said they would take treatment for
the symptoms, whereas 47(45.20%) did not know how
they would protect themselves if their partner had
symptoms of STI/RTIs.
Table 1: Demographic profile of study participants:
Demographic factors Number (%)
Gender Male 70 67.30
Female 34 32.70
Age group(yrs) 21-25 15 14.80
26-30 33 32.91
31-35 25 24.82
36-40 17 16.81
41-45 12 10.76
Educational
status
Illiterate 40 38.50
Primary 12 11.50
Secondary 48 46.20
H. Secondary 2
1.90
Graduate 2 1.90
Marital status Married 4 3.80
Unmarried 97 93.30
Separated 2 1.92
Widow 1 0.96
B.G.Prasad
Socioeconomic
Classification
a)Class I 3 2.88
b)Class II 38 36.53
c)Class III 46 44.23
d)Class IV 17 16.30
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Table 2: Knowledge regarding HIV/AIDS prevention & transmission among study participants
Knowledge of regarding HIV/AIDS Prevention and transmission Yes No Don’t know
Is HIV/AIDS Curable 14(13.5%) 45(43.30%) 45(43.30%)
HIV/AIDS Prevented By Consistent Condom Use 81(77.90%) 2(1.90%) 21(20.20%)
HIV/AIDS Prevented By Single Uninfected Sexual Partner 84(80.80%) 0(0.00%) 20(19.20%)
HIV/AIDS Prevented By Sterilized Needles And Syringes 75(72.10%) 1(0.96%) 28(26.90%)
HIV/AIDS Prevented By Blood/Blood Products Tested For HIV 76(73.10%) 0(0.00%) 28(26.90%)
HIV/AIDS transmission can occur By Sexual Intercourse Without A
Condom 84(80.80%) 0(0.00%) 20(19.20%)
HIV/AIDS transmission can occur by Infected blood/blood products 77(74.00%) 0(0.00%) 27(26.00%)
HIV/AIDS transmission can occur By Needles Syringes Infected With HIV 75(72.10%) 1(0.96%) 28(26.92%)
HIV/AIDS transmission can occur from Mother To Child During
Pregnancy 65(62.50%) 7(6.70%) 32(30.80%)
HIV/AIDS transmission can occur from Mother To Child During delivery 48(46.20%) 12(11.50%) 44(42.30%)
HIV/AIDS transmission can occur from Mother To Child through breast
milk 52(50.00%) 9(8.70%) 43(41.30%)
Table 3 Misconceptions Regarding HIV/AIDS
transmission
Misconceptions Regarding HIV/AIDS transmission
Yes (%) No (%)
Don’tknow
(%)
Person Get Infected By
Kissing On The Mouth 22(21.2) 16(15.4) 66(63.5)
Person Get Infected
By Mosquito Bites 23(22.1) 34(32.7) 47(45.2)
Person Get Infected By
Sharing A Common
Toilet 12(11.5) 39(37.5) 53(51)
Person Get Infected
By Bug Bites 15(14.4) 38(36.5) 51(49)
Table 4: Reported symptoms of STI/RTIs in studyparticipants
Reported Symptoms of STI/RTIs No. (%)
Urethral discharge 22 (31.42%)
Burning Micturition 42 (41.20%)
Genital ulcers 8 (7.69%)
Itching In Genital Area 33 (32.40%)
Inguinal Lymph nodes 17 (16.70%)
Chronic Lower Abdominal Pain 9 (8.80%)
Vaginal Discharge 21(61.76%)
DISCUSSION
The education status of study participants shows that
nearly 38(40%) of participants were illiterate, and only
4(3.84%) had studied beyond secondary school. Lack of
formal education may be one of possible causes of
migrating to Mumbai and it may influence sexual
behaviour choices. In National Behavioural Surveillance
Survey, 2006 carried out by NACO, it was seen that level
of awareness about HIV / AIDS was lower in illiterates
(45.8%) as compared to primary (77.7%), middle (91.6%),
secondary and higher secondary (98.2%) and graduate
and above (99.8%).[7]
As seen in table 2; by studying responses regarding the
existence of a cure for AIDS, 13.4% of participants thought
there is a cure for HIV/AIDS at present; almost similar to
12% and 14 % participants seen in other studies.[8, 9]
A
considerable knowledge gap is seen among study
participants as 30(29%) of participants do not have anyknowledge about prevention and transmission of
HIV/AIDS. Similarly in a study[10]
in 13 states of India, low
rates of knowledge and awareness were reported more
among rural women. This could be associated with lack of
formal education and media exposure. A study done
among slum-dwellers in another metropolitan city of India[11]
showed 67% males and 55% females were aware of
the sexual mode of transmission, as compared to 84% in
our study population.
About one fifth of the study population had misconceptions
regarding HIV/AIDS transmission as seen in table 3. Only
23% of participants in our study thought AIDS could
spread through mosquito bites, as compared to45% malesand 62% females in the above study.
[11]
Since Information education and communication (IEC)
strategies are important as components of behaviour
change in HIV/AIDS prevention among the general
population; possible interventional areas to address the
knowledge gap could be consistent involvement of visual
and print media, health education at each level of their
interaction with the formal health system along with
involvement of informal health care providers (unqualified
practitioners). Health education through all the above
channels may also dispel misconceptions regarding
HIV/AIDS transmission and act also aid in reducing stigmaand discrimination against people living with
HIV/AIDS(PLHA) in families and general population.
Age at first sexual intercourse was less than 21 years for
85(81.70%) of participants which includes the 12-16 years
age group in 23(22.10%) participants, similarly is also
seen in other studies.[12]
This observation may lead to
suggestion of initiation of sex education/family life
education both in formal and informal setups at an earlier
age group possibly at eight to nine years of age. In
informal setups; for out of school children different
strategies may have to be explored for e.g. peer
facilitators, adolescent groups for girls etc.
On exploring the reasons for not using condoms, 9(8.70%)
revealed they had no knowledge of how to use a condom,
indicating further strengthening of IEC and health
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education component. Cultural beliefs might moderate the
way in which STI/HIV is perceived and therefore
addressed in that particular context.[13]
Addressing risky
sexual practices such as early sexual debut is one
strategy which could lead to lower risk for RTI/STIs and
HIV/AIDS among slum dwellers.
Reported symptoms of STI were seen in both males
(31.4%) and females (61.76%), compared to a study in
Nigeria[14] where 27% of males and 10% of females
reported symptoms of STI/RTIs .Women are more
vulnerable to RTI/STIs. Out of 47(45.20%) study
participants who did not know how they would protect
themselves if their partner had symptoms of STI/RTIs, 30
(88.23%) were women. Teaching assertiveness skills in
sexual and reproductive health areas for women in slums
can an important interventional area.
Lack of awareness of symptoms of STI/RTIs coupled with
less priority given to women and their health could be
possible reasons for high reported prevalence seen in
women participants.
CONCLUSION
Urban slum residents in Mumbai have knowledge gap
regarding HIV/AIDS transmission and prevention. Initiation
of sexual intercourse is at an early age, they report
symptoms of STI/RTI and are making unsafe sexual
behavioural choices. These findings highlight the need to
possibly treat slum residents as a sub-population
vulnerable to reproductive health problems and may
require allocation of more/special innovatively packaged
resources for interventions in slums. At individual level, the
interventions would focus on behaviour change; aimed at
HIV / AIDS prevention and at community level they may
focus on raising awareness and reducing stigma regarding
both STI/RTI and HIV/AIDS, thus empowering
communities in fighting the battle against HIV/AIDS.
ACKNOWLEDGMENT: Nil
Conflict of Interest: Nil
REFERENCES
1. International Institute for Population Sciences (IIPS)
and Macro International. 2007. National Family Health
Survey (NFHS-3), 2005–06: India: Volume I. Mumbai:
IIPS.
2. AIDS control program. http://www.naco.gov.in/
NACO/National_AIDS_Control_Program/Prevention_
Strategies/ [Last accessed on March30 2015]
3. http://www.unaids.org/en/regionscountries/countries/i
ndia[Last accessed on February 28 2015]
4. http://www.worldbank.org/en/news/feature/2012/07/10
/hiv-aids-india[Last accessed on March30 2015]
5. Madise N. J. Are slum dwellers at heightened risk of
HIV infection than other urban residents? Evidence
from population-based HIV prevalence surveys in
Kenya. Health Place. 2012;18(5): 1144–152.
6. K. Park, Epidemiology of Communicable Diseases,
Parks Textbook of Preventive and Social Medicine,
22ndedition M/S Banarasidas Bhanot publishers;2013;
399-05.
7. National Behavioral Surveillance Survey – General
population. National AIDS Control Organization,
Ministry of Health and Family Welfare, Government of
India. 2006;36:108
8. Unnikrishnan B, Mithra PP, T R, B R. Awareness and
attitude of the general public towards HIV/AIDS in
Coastal Karnataka. Indian J Community
Med. 2010;35:142–6.
9. Sobhan K, Kumar TS, Kumar GS, Ravikanth R,
Adarsha S, Mohammad AS, et al. HIV and AIDS:
Awareness and attitudes among males in a rural
population. Indian J Community Med 2004;29:141 -2.
10. Balk D, Lahiri S. Awareness and knowledge of AIDS
among Indian women: Evidence from 13 States.
Health Transit Rev. 1997; 7:421-65
11. Kalasagar M, Sivapathasundharam B, Einstein T,
Bertin A. AIDS′s awareness in an Indian metropolitan
slum dweller: A KAP (knowledge, attitude, practice)
study. Indian J Dent Res 2006;17:66-9.
12. Zulu E, Dodoo F, Ezeh A. Sexual risk-taking in theslums of Nairobi, Kenya, 1993–98. Population
Studies. 2002;56(3):311–23
13. UNESCO UNAIDS: Handbook appropriate
communication for behavior change:
Information/Education/Communication. A cultural
approach to HIV/AIDS Prevention and
Care.2001. http://unesdoc.unesco.org/images/0012/0
01255/125589e.pdf.
14. Adedimeji AA, Omololu FO, Odutolu O. HIV risk
perception and constraints to protective behaviour
among young slum dwellers in Ibadan, Nigeria. J of
Health, Popu & Nutri.2007; 13(2):146–57.
8/20/2019 Ijmrhs Vol 4 Issue 4
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Available online at: www.ijmrhs.com DOI: 10.5958/2319-5886.2015.00145.9
Research article Open Access
COST ANALYSIS OF LONG ESTABLISHED AND NEWER ORAL ANTIEPILEPTIC
DRUGS AVAILABLE IN THE INDIAN MARKET
*Phatak Abhishek M1, Hotwani Jitendra H
2, DeshmukhKiran R
3, Panchal Sagar S
1, Naik Madhura S
1
INTRODUCTION
Epilepsy is a chronic non-communicable disorder of the
brain that affects people of all ages often interfering with
education and employment. Epilepsy is defined by
International League Against Epilepsy (ILAE) as a
condition characterized by recurrent (two or more)
epileptic seizures, unprovoked by any immediate
identified cause.[1]
According to the World Health
Organization (WHO), of the 50 million people with
epilepsy worldwide, 80% reside in developing countries.[2]
It is estimated that there are more than 10 million persons
with epilepsy in India. Its prevalence is about 1% in Indian
population.[3]
The prevalence is higher in the rural (1.9%)
compared to urban population (0.6%).[4,5]
The estimated
burden of epilepsy using the disability adjusted life years
(DALYs) accounts for 1% of the total burden of disease in
the world, excluding that due to social stigma and
isolation, which further add to the disease burden.[6]
In many developing countries, people with epilepsy do not
receive appropriate treatment for their condition, a
phenomenon called treatment gap (TG), which is defined
as the number of people with active epilepsy not on
treatment (diagnostic and therapeutic) or on inadequatetreatment, expressed as a percentage of the total number
with active epilepsy.[7]
The magnitude of epilepsy
treatment gap in India ranges from 22% among urban,
middle-income people to 90% in rural India.[8]
In order to reduce this gap in the context of limited
resources, it would be necessary to specify the important
causes of gap for a particular community and the most
cost-effective resource
for a particular situation.[9,10-12]
The Indian pharma market
size is expected to grow to US$ 85 billion by 2020. The
growth in Indian domestic market will be on back of
increasing consumer spending, rapid urbanization, and
raising healthcare insurance and so on.[13]
The cost of drug plays a crucial role in patients care
especially in developing countries and constitutes an
essential part of rational drug prescription. In recent years
more emphasis has been given on cost effective practice
which should be adopted by clinicians. Cost of drugs is an
important factor influencing compliance with treatment.[14]
The epileptic seizures are a common disorder for which
patients have to take medication for a prolonged period,
sometimes even life-long. It is necessary for the clinicians
to prescribe most effective, appropriate and economical
treatment regimen available.Estimation of the economic burden of epilepsy is of pivotal
relevance to enable a rational distribution of healthcare
resources. Being one of the common brain disorders with
ABSTRACT
Background: Large number of pharmaceutical companies manufactures
antiepileptic drugs in India. The price variations among the marketed drugs are
wide. Aims: The present study was aimed to find the cost of different oral
antiepileptic drugs available in Indian market as monotherapy, combination
therapy and number of manufacturing companies for each, to evaluate
difference in cost of different brands of same dosage of same active drug by
calculating percentage variation of cost. Methods and Materials: Cost of a drug
being manufactured by different companies, in the same strength and dosage
forms was obtained from “Indian Drug Review” Vol. XXI, Issue No.4, 2014 and
“Current Index of Medical Specialties” July-October 2014. The difference in the
maximum and minimum price of the same drug manufactured by different
pharmaceutical companies and percentage variation in price was calculated.
Results: The percentage price variation noted of long-established drugs was –
Phenytoin (50mg): 140%, Carbamazepine (100mg): 1033%, Phenobarbital
(30mg) : 730%, Valproic acid (300mg) : 420%. Newer drugs –Levetiracetam
(250mg): 75%, Lamotrigine (25mg): 66%, Topiramate (50mg): 108%,
Zonisamide (100mg): 19%. Combination drugs – Phenobarbital + Phenytoin
(30+100) mg: 354.55%. Conclusion: The percentage price variation of different
brands of the same commonly used long-established oral antiepileptic drug
manufactured in India is very wide. The formulation or brand of Antiepileptic
drugs (AEDs) should preferably not be changed since variations in
bioavailability or different pharmacokinetic profiles may increase the potential for
reduced effect or excessive side effects. Hence, manufacturing companies
should aim to decrease the price variation while maintaining the therapeutic
efficacy.
ARTICLE INFO
Received: 2nd May 2015Revised : 14th July 2015Accepted: 29th July 2015
Authors details: 1Third Year Junior Resident, 2 Associate Professor, 3SecondYear Junior Resident, Department of Pharmacology, Topiwala NationalMedical College and B. Y. L. Nair Charitable Hospital, Mumbai Central,Mumbai, Maharashtra, India
Corresponding author: Phatak Abhishek M.
Topiwala National Medical College and
B. Y. L. Nair Charitable Hospital,
Mumbai Central, Maharashtra, India
Email: [email protected]
Keywords: Therapeutic drug
monitoring, Bioavailability,
Carbamazepine, Topiramate. Treatment
gap
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varying etiologies, which can present at any age, requiring
prompt therapy and with the aim to promote rational
pharmacotherapy we decided to study the cost of different
brands of antiepileptic drugs available in Indian market.
MATERIALS AND METHODS
Study design: This was an analytical study.
Exclusion criteria: The drug formulation being
manufactured by only one company was excluded.The study was conducted by the Department of
Pharmacology, Topiwala National Medical College &
B.Y.L. Nair Charitable Hospital, Mumbai.
Methodology: Price in Indian rupees (INR) of oral
antiepileptic drugs manufactured by different
pharmaceutical companies in India, in the same strength
was obtained from “Indian Drug Review” (IDR) Vol. XXI,
Issue No.4, 2014 and “Current Index of Medical
Specialties”(CIMS)(15)
July-October 2014. The prices of 18
oral antiepileptic drugs (16 single and 2 combinations),
available in 56 different formulations were analyzed.
Cost of the oral antiepileptic drug formulation was
calculated for an average of 10 tablets as the number of tablets available per strip varied. Difference in the
maximum and minimum price of the same drug
formulation manufactured by different pharmaceutical
companies and percentage variation in price was
calculated.
Percentage cost variation was calculated as follows:[14]
%CV= Price of most expensive brand– least expensive brand × 100
Price of least expensive brand
(CV= Cost variation)Statistical analysis: Findings of our study were
expressed as absolute numbers as well as percentage.
RESULTS
Table 1 shows variation in cost of long - established oral
antiepileptic drugs used as a single drug therapy. The
percentage variation noted in the cost was -
Carbamazepine (100 mg): 1033%, Phenobarbital (30 mg):
730%, Valproic acid (300 mg): 420%, Divalproax sodium
(500 mg): 378% and Diazepam (5 mg): 374%.
Table 2 shows variation in cost of oral antiepileptic drugs
used in combination. The percentage variation noted in
the cost was Sodium valproate + Valproic acid (333+145
mg): 76.67%, Phenobarbital + Phenytoin (30+100 mg):
354.55%.
Table 3 shows variation in cost of newer oral antiepilepticdrugs used as single drug therapy. The percentage
variation noted in the cost was - Pregabalin (75 mg):
143%, Topiramate (50 mg): 108%, Levetiracetam(250
mg): 75%, Oxcarbazepine (150 mg): 59%.
Table 1: Price variation in long-established oral antiepileptic drugs
Drug Formulation Doses(mg) No.of Manuf.Companies
Minimum price(INR)
Maximum price(INR)
% Pricevariation
Carbamazepine 4 100 13 6.18 70.00 1033
200 22 11.17 120.00 974
300 5 18.24 28.28 55
400 11 24.24 37.71 56
Phenytoin 3 50 3 7.49 18.00 140
100 9 8.36 21.10 152300 2 50.19 56.66 13
Phenobarbitone 2 30 3 4.95 41.08 730
60 3 8.25 28.02 240Divalproexsodium
7 125 7 17.00 30.30 78250 21 24.00 84.00 250
500 25 32.00 153.00 378
750 9 85.00 106.05 25
1000 6 99.00 115.00 16
200 3 29.50 35.00 19
300 3 41.00 55.00 34
Valproic acid 3 200 15 19.50 42.00 115300 8 25.90 56.00 420
500 9 39.90 93.00 133Diazepam 3 2 3 12.65 20.20 60
5 9 7.00 33.21 37410 8 11.75 40.85 248
Lorazepam 2 1 11 7.80 30.00 285
2 10 10.59 35.00 230
Clonazepam 4 0.25 9 7.00 16.25 132
0.5 23 9.63 45.00 367
1 13 12.50 37.00 1962 16 31.68 67.00 111
Clobazam 3 5 9 23.00 53.52 133
10 9 43.00 106.37 147
20 4 79.90 146.00 83
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INR: Indian rupees. The prices of 18 oral antiepileptic drugs (16 single and 2 combinations), available in 56 different
formulations were analyzed.
Table 2: Price variation among combination therapy
Drug Formulation Doses
(mg)
No of Manufa.
Companies
Minimum
price (INR)
Maximum price
(INR)
% Price
variation
Na valproate+
valproic acid
2 200+87 7 36.50 62.50 71.23
333+145 7 60.00 106.00 76.67Phenobarbital+
phenytoin
1 30+100 3 6.60 30.00 354.55
INR: Indian rupees, Na: sodium
Table 3: Price variation in newer oral antiepileptic drugs
Drug Formulation Doses
(mg)
No. of
Manufacturing
Companies
Minimum price
(INR)
Maximum price
(INR)
% Price
variation
Lamotrigine 3 25 4 30.00 50.00 66
50 7 54.50 90.00 65
100 7 98.00 158.00 61
Gabapentin 3 100 3 36.20 44.00 22
300 10 98.75 131.00 33
400 5 119.50 152.00 27
Pregabalin 3 50 2 58.20 59.00 1
75 17 56.83 138.00 143
150 14 114.14 169.00 48
Topiramate 3 25 4 19.00 38.00 100
50 4 36.00 75.00 108
100 2 108.00 158.00 46
Levetiracetam 4 250 5 55.00 96.00 75
500 5 110.00 189.00 72
750 4 168.00 280.00 67
1000 2 290.00 360.00 24
Zonisamide 2 50 2 57.00 59.40 4
100 3 87.79 104.70 19
Oxcarbazepine 4 150 11 26.39 42.00 59
300 12 48.33 75.00 55
450 2 110.00 120.00 9
600 10 90.00 134.00 49
INR: Indian rupees
DISCUSSION
The epilepsies are a spectrum of brain disorders rangingfrom mild, benign forms to severe, life-threatening and
disabling ones. Epilepsies can occur in children, adults
and the elderly, as well as following brain trauma, stroke,
and brain tumors. There is lack of sufficient data in India
comparing the cost of the same antiepileptic drug sold
under different brand names by different pharmaceutical
companies.[15]
The drug prices available in CIMS and IDR were
compared as they are one of the available sources of
drug information that are updated on a regular basis.
In our study, we have found that there were 56
formulations of antiepileptic drugs of which 31 were of
long-established antiepileptic drugs, 22 of newer and 3 of
combination drugs. So it is not practically possible for any
health care provider to remember the prices of all thesebrands.
Variations in costs were found to be significant. The ones
with significant variations were the cost of the brands of
Carbamazepine 100mg varied from Rs.6.18 to Rs.70.00;
Phenobarbital 30mg varied from Rs.4.95 to Rs.41.08.
Valproicacid 300mg cost varied from Rs.25.90 to Rs.
56.00. Among newer antiepileptics, Pregabalin 75mg
varied from Rs.56.83 to Rs. 138.00; Topiramate 50 mg
cost varied from Rs. 36.00 to Rs. 75.00. Among the
combination therapy, Phenobarbital + Phenytoin (30
mg+100 mg) showed maximum price variation i.e.
354.55%.
Thus, in our study of cost-analysis of various anti-epileptic
brands, it has been observed that there is substantial
variation in the cost of different brands of same generic
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drugs. Anand Krishnan, Ritvik, DebashishChowdhary
(2007) have also observed a lot of variation in the cost of
anti-epileptic drugs.[16]
Findings of our study is similar to
their studies. The intrabrand comparison of newer anti-
epileptic drugs also showed wide variation in the cost. Our
study is in agreement with the study of Beghi, Ettore, et al
(2008) as they have noticed a higher cost of newer anti-
epileptic drugs.[17]
The reasons for this price variation could be as follows- [18]
1. Government regulations and pricing policies
2. The existing market structure of the pharmaceutical
industry
3. Industry costs
Drugs are the mainstay of treatment for epilepsy, and are
effective for most patients. It is switching from brand-
name to generic antiepileptic or from one generic
antiepileptic to another that should be avoided in clinical
practice, since subtle differences in bioavailability may
disturb optimal degree of seizure control to which the
patient was previously successfully titrated.[19]
Even using
a parent compound, antiepileptic medication levels canfluctuate if the product source has changed, resulting in
toxicity.[20]
In this regard, therapeutic drug monitoring
becomes essential specially for phenytoin since it has
narrow therapeutic index. It is vital therefore those
patients should receive the same brand consistently to
avoid loss of control.
In India, a large number of patients are not covered under
any individual or government medical insurance. Hence,
the patients have to purchase the prescribed drugs by
themselves. These wide variations in the prices of
different formulations of the same drug have severe
economic implications on the Indian Population.
The Government of India has unveiled ’Pharma Vision2020’ aimed at making India a global leader in end-to-end
drug manufacture. It has reduced approval time for new
facilities to boost investments. Further, the government
has also put in place mechanisms such as the Drug Price
Control Order (DPCO) and the National Pharmaceutical
Pricing Authority (NPPA) to address the issue of
affordability and availability of medicines.
There are few antiepileptic drugs included in The National
list of essential medicines but still there are many drugs
especially the newer antiepileptic drugs such as
oxcarbazepine, topiramate etc. having better safety,
efficacy profile but not included in the list.
[21-24]
Limitations of this study: Being sources of information
were limited to IDR and CIMS. There are various other
brands which are marketed in India but not published in
the above mentioned sources. Also we have not
assessed the prices of parenteral preparations.
CONCLUSION
The percentage price variation of different brands of the
same antiepileptic drug manufactured in India is very
wide. Considering the prevalence of epilepsy especially in
rural India where there are limited resources and poverty,
providing a broad overview of available antiepileptic drugs
and their prices is of utmost importance.There should be
education programs and marketing strategies so that
prescribers can select proper medication for their patients
which is cost-effective, tolerable as well as efficacious in
accordance to the principles of rational pharmacotherapy.
Acknowledgment: We Acknowledge Department of
Pharmacology and Central library, Topiwala National
Medical College & B.Y.L. Nair Charitable Hospital,
Mumbai, for their support.
Source of Support: Nil
Conflict of Interest: NoneREFERENCES
1. Hauser WA, Kurland LT. The epidemiology of
epilepsy in Rochester, Minnesota. Epilepsia. 1975;
16:1-66.
2. WHO. Neurological Disorders: Public Health
Challenges. Geneva: World Health Organization;
2006.
3. Sridharan R, Murthy BN. Prevalence and pattern of
epilepsy in India. Epilepsia. 1999; 40:631-636.
4. Leonardi M, Ustun TB. The global burden of epilepsy.
Epilepsia. 2002; 43(6):21-25.5. Pahl K, de Boer HM. Epilepsy and rights. Atlas:
Epilepsy Care in the World. Geneva: WHO; 2005:72-
73.
6. Jain S, Satishchandra P. Epilepsy: A Comprehensive
Textbook. . In: Engel J Jr, Pedley TA, editors. New
York: Cambridge University Press, Lippincott
Williams and Wilkins; 2008. pp. 2885-2889.
7. Meinardi H, Scott RA, Reis R, Sander JW. ILAE
Commission on the Developing World. The treatment
gap in epilepsy: The current situation and ways
forward. Epilepsia. 2001; 42:136-149.
8. Meyer AC, Dua T, Ma J, Saxena S, Birbeck G. Global
disparities in the epilepsy treatment gap: Asystematic review. Bull World Health Organ. 2010;
88:260-266.
9. Bharucha NE, Bharucha EP, Bharucha AE, Bhise
AV, Schoenberg BS. Prevalence of epilepsy in the
Parsi community of Bombay. Epilepsia. 1988;
29:111-115.
10. Koul R, Razdan S, Motta A. Prevalence and pattern
of epilepsy (Lath/Mirgi/Laran) in rural Kashmir, India.
Epilepsia. 1988; 29:116-122.
11. Mani KS. Epidemiology of epilepsy in Karnataka,
India. Neurosci Today. 1997; 1:167-74.
12. Pal DK. Methodological issues in assessing riskfactors for epilepsy in an epidemiologic study in India.
Neurology. 1999; 53:2058-2063.
13. Consolidated FDI Policy, Department of Industrial
Policy & Promotion (DIPP), Press Information Bureau
(PIB), Media Reports, Pharmaceuticals Export
Promotion Council. Available from
[accessed on 25 April, 2015]
14. Ravi Shankar P, Subish P, Bhandari RB, Mishra P,
Saha AC. Ambiguous pricing of topical
dermatological products: A survey of brands from two
South Asian countries. Journal of Pakistan
Association of Dermatologists. 2006; 16:134-140
8/20/2019 Ijmrhs Vol 4 Issue 4
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Phatak et al., Int J Med Res Health Sci. 2015;4(4):744-748
15. Jadhav NB, Bhosale MS, Adhav CV. Cost analysis
study of oral antidiabetic drugs available in Indian
market. Int J Med Res Health Sci. 2013; 2(1): 63-69.
16. Sridharan R. Epidemiology of epilepsy. Current
Science. 2002; 82:664-670.
17. Goel D, Agarwal A, Dhanai JS, Semval VD, Mehrotra
V, Saxena V, et al. Comprehensive rural epilepsy
surveillance programme in Uttarakhand state of India.
Neurol India. 2009; 57:355-356.18. Banerjee TK, Ray BK, Das SK, Hazra A, Ghosal MK,
Chaudhuri A, et al. A longitudinal study of epilepsy in
Kolkota, India. Epilepsia. 2010; 51:2384-2391.
19. Jancovic SM, Ignjatovic RD, Is bioavailability altered
in generic versus brand anticonvulsants? Expert
Opinion on Drug Metabolism Toxicology. 2015;
11(3):329-332.
20. Patel V, Cordato DJ, Dias M, Beran RG, Changed
constitution without change in brand name--the risk of
generics in epilepsy. Epilepsy Research. 2012; 98(2-
3):269-272.
21. National Pharmaceutical Pricing Authority,Government of India. Available at
http://www.nppaindia.nic.in/
DPCO2013.pdf.[Accessed on 18 April 2015].
22. National Pharmaceutical Pricing Authority,
Government of India, Current Price list. Available at
http://www.nppaindia.nic.in/ceiling/press28april14/so1
156e-28-4-14.html.[Accessed 18 April 2015].
23. National List of Essential Medicines of India.
Available at: http://www.mohfw.nic.in/WriteReadData/
l892s/7364497513National%20List%20of%20Essenti
al%20Medicine,%202011.pdf.[Accessed 18 April
2015].
24. Rang HP, Ritter JM, Flower RJ, Henderson G,
Rang& Dales Pharmacology. 7th
edition, Elsevier
Churchill Livingstone, Spain; 2012, pp. 540-552.
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Available online at: www.ijmrhs.com DOI: 10.5958/2319-5886.2015.00146.0
Research article Open Access
ROLE OF DIETARY DIVERSITY IN ENSURING ADEQUATE HAEMATOLOGICALSTATUS DURING PREGNANCY
Mahama Saaka1
Abdulai Abdul Rauf 2
INTRODUCTION
In most developing countries maternal under nutrition
including micronutrient deficiencies is a leading cause of
maternal and child mortality and morbidity[1]. Anaemia in
particular is one of the most prevalent public health
problems in Ghana. Anaemia is defined as a condition in
which the number and size of red blood cells or
haemoglobin concentration falls below an established cut
-off, consequently impairing the capacity of the blood to
transport oxygen around the body[2]
. According to recent
estimates, anaemia affects 60.0% pregnant women in
developing countries including Ghana and about 7.0 % of
cases are severe[3,4]
.
The aetiological factors responsible for anaemia in
pregnancy are multiple and their relative contributions are
said to vary by geographical area and by season[5]
. Admittedly, several predisposing factors contribute to
anaemia among pregnant women and these include socio-
demographic, socio-economic status, multiparity, short
inter-pregnancy intervals and nutritional factors[6]
. The
relative importance of each of these varies from place to
place. In the Northern Region of Ghana, where anaemia is
of public health significance, very little is documented
regarding the role maternal dietary factors contribute to
haematological status. The role of diet on blood
biomarkers may be significant, but evidence of the
magnitude of this benefit is limited.
An understanding of association between dietary diversity
and haematological status may be complicated by other
factors including malarial infection and household socio-
economic status. This study sought to determine the
independent contribution of dietary diversity to
haematological status of pregnant women whilst
controlling for potential confounding factors. We
hypothesized that diversified diets during pregnancy would
be associated with better haematological status compared
to nutrient-poor diets.
MATERIAL AND METHODS
Study design: This study was analytical cross-sectional
design from January- March 2013.
Sample size: 307 was calculated using single population
proportion formula assuming the prevalence of all types of
anaemia among pregnant women in Northern Region was
estimated as 73.0 %[7]
, confidence interval 95%, margin
of error 5.0 %. Systematic random sampling procedurewas used to select the study participants. The attendance
list of the women who sought ante-natal care services
served as the sampling frame.
Ethical approval: The protocol for this study was
approved by the School of Medicine and Health Sciences,
University for Development Studies. Informed consent was
obtained from all study participants. Information about
objective of the study, procedures, potential risks, and
benefits was given to mothers before they were enrolled to
the study. Their full right to refuse participation was
explained. Written informed consent was obtained from
each mother/caregiver.Inclusion criteria: The study population comprised
pregnant women who sought antenatal care at four major
ABSTRACTIntroduction: Though nutrition is a key input to blood formation, little is
known about the extent maternal dietary quality contributes to the
haematological status of pregnant women in Northern Region of Ghana.
Objective: The aim of this study was to assess the independent
contribution of dietary diversity to haematological status of pregnant women
whilst controlling for potential confounding factors including malarial
infection. Methods: A cross-sectional study design was used on a sample
of 307 pregnant women in their third trimester. A structured questionnaire
was used to collect socio-demographic characteristics, obstetric and dietary
data related to anaemia. Overall dietary quality was assessed using the
dietary diversity score. Haemoglobin concentration (Hb) was measured
using portable HemoCueR Hb 301 system. Predictors of anaemia were
estimated using multiple linear regression analysis. Results: The mean Hb
was 10.8±1.4 g/dl and prevalence of anaemia (Hb
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hospitals in Tamale Metropolis of the Northern region of
Ghana.
Data Collection; The study participants were recruited in
their third trimester (34-36 weeks gestation). Study
participants were then interviewed face-to-face by the
investigators. A pre-tested questionnaire was used to
collect information including haemoglobin concentration,
blood pressure, weight, maternal age, parity, gestational
age, level of education and occupation of the women,
history of malarial infection in the index pregnancy (self-
reported fever or laboratory-tested), presence of any
chronic illnesses, and prophylactic medications received
during pregnancy. Standard procedures were followed for
the recording of blood pressure and weight.
Independent and dependent variables
The main outcome variable for this study was the
prevalence of anaemia (Hb less than 11 g /dl). The
independent variables for this study were maternal, child
and household characteristics including antenatal care
(ANC) attendance, malarial infection, maternal dietary
intake. A brief description of main independent and dependent
variables is as follows:
Diagnosis of anaemia : Haemoglobin concentration
levels were measured in late pregnancy (gestational age
≥34 weeks) using a portable haemoglobinometer made by
HemoCue® Hb301. Capillary blood was collected from
participants using a finger prick method under sterile
conditions. The first drop of blood was wiped away using
alcohol sterile wipes, and the next drop was placed into
the Hemocue curvette for immediate testing of
haemoglobin. Women were classified as anaemic if they
had a haemoglobin concentration less than 11 g/dL.
Anaemia was further classified as mild (9.0-10.9 g/dL),
moderate (7.0-8.9 g/dL) or severe (
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mothers was 27.2±4.0 years which ranged from 18 to 38
years. Majority (75.2%) of the respondents were Muslims.
Majority, 245 (79.8%), of the respondents were married
and (47.9 %) of the mothers had no formal education at
all. Petty trading was common among the mothers and
most of the participants (67.1%) were multigravida (Table
1).
Table 1: Sample Characteristics (N =307)
Frequency (n) Percentage (%)
Religion
Islam 231 75.2
Christianity 76 24.8
Classification of occupation
None 97 31.6
Petty trader 108 35.2
Farmer 72 23.5
Civil Servant 30 9.8
Tribe
Dagomba 180 58.6
Gonja 36 11.7
Mamprusi 34 11.1
Nanumba 28 9.1
Akan 12 3.9Others 17 5.5
Education level of mother
None 147 47.9
Primary 41 13.4
JSS/Middle 50 16.3
Secondary 47 15.3
Tertiary 22 7.2
Marital status
Single 62 20.2
Married 245 79.8
Gravidity
Primigravida 32 10.4
Secundigravida 69 22.5Multigravida 206 67.1Magnitude of Anaemia: The mean hemoglobin level was
about 10.8±1.4 g/dL which ranged from 7.3 g/dL to
14.3 g/dL. The prevalence of anaemia was 46.3%. In
terms of severity, mild anaemia was 34.9 %, moderate
anaemia was 11.4 % but there were no cases of severe
anaemia.
Factors Associated with Anemia: Bivariate analyses
were performed to assess association of socio-
demographic and other maternal factors with child anemia
(Table 2). There was an inverse relationship between the
prevalence of anaemia and the level of education of the
women. This means the proportion of anaemic womendecreased with increased in the level of education.
Anaemia was significantly more common in women of
lower household wealth index. As maternal 7-day dietary
diversity increased, the prevalence of anaemia decreased.
As the number of sulfadoxine-pyrimethamine (SP) doses
increased the prevalence of malaria decreased.
Dietary Diversity and Food Group Frequency
Consumption
In late pregnancy, the minimum dietary diversity (that is,
proportion of women who receive foods from 5 or more
food groups in seven days was 85.5 %. The mean dietary
diversity score (DDS) from 11 food groups was 9.1±1.4.
The mean food group frequency of consumption (past 7
days) was 15.0±2.8. The minimum and maximum of the
food group frequency of consumption index scores were
6.0 and 22 respectively. More than half of the pregnant
women (52.8%) were on low diversified diet as measured
by DDS over a period of one week. A significant proportion
of the pregnant women rarely consumed dairy products
and eggs though over 80 % of consumed cereals and
roots & tubers on a daily basis (Table 3).
Table 2a: Bivariate Analysis of predictors of anaemia
among pregnant women
Characteristic
N Anaemia
No n (%)
Yes n (%)
Teststatistic
Maternal Education
None 147 78 (53.1) 69(46.9) χ =15.2p= .001Low 91 36 (39.6) 55(60.4)
High 63 45 (71.4) 18(28.6)Religion of mother
Islam 227 110(48.5) 117(51.5) χ = 7.1p=.008Christianity 74 49 (66.2) 25(33.8)
Marital status
Single 60 23 (38.3) 37(61.7)
Married 241 136(56.4 ) 105(43.6) χ = 6.3p=.012
Malarial infection
None 45 30 (66.7) 15 (33.3) =14.5p=0.0011-2 times 223 121(54.3) 102(45.7)
3-4 times 33 8 (24.2) 25 (75.8)
Maternal 7-day dietary diversity
Low 162 71 (43.8) 91 (56.2) χ =11.4p=.001
High 139 88 (63.3) 51 (36.7)
Table 2b: Bivariate Analysis of predictors of anaemia
among pregnant women
Characteristic
N Anaemia
No
n (%)
Yes
n (%)
Teststatistic
Household wealth index
Low 160 71 (44.4) 89 (55.6) χ = 9.7
p =
0.002High 141
88 (62.4) 53 (37.6)
ANC visit
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3 doses 111 65 (58.6) 46(41.4) 0.012
Table 3: Food groups consumption frequency in the past week (n= 307)
Frequency of foods consumption in the past week (% of women)
Type of food Usually every day 4 to 6 times per week 1- 3 times per week Never/rarely
Meat 58.0 34.2 7.2 0.7
Poultry 2.3 19.2 50.8 27.7
Liver 14.3 43.0 53.8 6.8
Fish 18.6 30.6 41.7 9.1Cereals 97.1 2.3 0.7 0.0
Roots & tubers 84.7 11.7 1.3 2.3
Legumes 58.0 34.9 7.1 0.0
Dairy products 2.0 22.8 45.0 30.2
Eggs 4.2 16.3 39.4 40.1Fruits 22.5 30.6 36.2 10.7
Green leafy vegetables 37.5 44.6 14.3 3.6
Table 4: Determinants of Hb in the third trimester of pregnancy
Model StandardizedCoefficients
Sig. 95.0% Confidence Intervalfor (β)
CollinearityStatistics
Beta (β) Lower Bound Upper Bound Tolerance VIF
(Constant) 7)
0.239
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past research that showed a high prevalence of anaemia
among women in Northern Ghana[7,17,18]
.
Most of the women in this study had anaemia of mild to
moderate severity with no case being severely anaemic.
These findings are similar to the findings from other
studies in which 47.5 % of women aged 15-49 years had
some form of anaemia[17]
.
Dietary diversity and haematological status: The
results of this study showed that high maternal dietary
diversity was associated with reduced risk of anaemia and
so nutritional factors may be important. This finding is
consistent with that of similar studies carried out
elsewhere in India, where low dietary intake of multiple
micronutrients, but higher intakes of nutrients that inhibit
iron absorption such as calcium and phosphorus, may
help explain high rates of maternal anaemia[19]
.
It has earlier been reported that some pregnant women do
restrict dietary intake in order to have smaller babies, and
therefore easier deliveries[20,21]
. In Ethiopia, women with
restrictive dietary habits were reported of 39 % higher risk
of anaemia compared to those without restrictive dietary
behavior [22]
and where maternal dietary diversity wasprotective of pregnancy anaemia
[23,24]. Studies conducted
in Pakistan and Turkey also reported that consumption of
fruit two or more times per week is associated with a
decreased risk of anemia[25,26]
.
Diet is an important factor for anaemia, as some eating
patterns or habits may predispose individuals to a higher
risk for developing anaemia. For example, high fibre diets
can inhibit the absorption of iron; low fat diets can equally
inhibit iron absorption since fat is needed for iron
absorption, high tea and coffee consumption but without
vitamin C intake inhibits iron absorption. Poor dietary
diversity leads to deficiency of minerals and vitamins
which may increase bio-availability of iron then affects Iron
status[27]
.
Dietary diversity is considered to be a key indicator for
assessing the access, utilization, and quality of diet of
individuals or household[28]
. Individual dietary diversity
scores have been shown to indicate adequate nutrient
intake through diet and it can be used as a proxy indicator
for measuring nutrient adequacy among pregnant females[29]
.
A pregnant woman’s diet that lacks diversity is most likely
to be deficient in essential nutrients and as a result the
foetus will not be provided the nutrition it requires to have
a healthy growth[30]
. Women’s dietary behaviours andintake during pregnancy are strongly influenced by
different cultural practices, myths and taboos[31,32]
.
During pregnancy, dietary energy and nutrient
requirements are generally increased to support increased
maternal metabolism, blood volume and red cell mass
expansion, and the delivery of nutrients to the fetus. Key
nutrients including folate, iron, zinc, calcium, vitamin D,
and essential fatty acids function to promote red blood cell
production, enzyme activity, bone development, and brain
development. Poor maternal dietary quality may thus have
serious implications for anaemia during pregnancy[33]
.
Haematinics, particularly iron contributes to the rise in
serum erythropoietin which often decreases during
pregnancy. Deficiency of these essential haematinics
arising from increased requirements and inadequate
intake may have far reaching effects on both mother and
foetus.
Parity, gravidity and haematological status: On the
average, increased parity was associated with decreased
Hb concentration. It is generally believed that anaemia in
pregnancy increases with rising parity, due to repeated
drain on iron stores[34]
. However, the association between
high parity and anaemia in pregnancy is not unequivocal.
While some studies show high parity increases risk[35,36]
,
others show no increased risk [19].
However, the prevalence of anaemia decreased with
gravidity, ranging from 75% among primigravidae to 43.7
% among multigravidae.
ANC attendance and anaemia: The content of ANC
services received and early initiation were found to be
associated with lower odds of having anaemia in the third
trimester. The percentage of women with anaemia was
lowest among those that booked for antenatal care in the
first trimester. This finding is in agreement with findings of
Komolafe et al.[4]
and Bukar et al.[37]
in Nigeria. The
positive contribution of early initiation of ANC attendance
to haematological status is probably due to the benefitsassociated with ANC. For example, women who initiate
ANC visits early are more likely to benefit from
prophylactic measures against malarial infection, iron and
folic acid supplementation and that of nutrition and health
education. There is an increased foetal demand for
haematopoietic factors as pregnancy progresses and so
women who will not avail themselves to health services
early enough may suffer the consequences of increased
demand for nutrients. Such women are also more likely to
take advantage of accessing health services to treat any
underlying maternal diseases and untreated anaemia in
early pregnancy that are likely to worsen in the course of
pregnancy.
Limitation of the study: This study was hospital based
and as such may not be truly reflective of the situation in
the district due to selection bias. Pregnant women utilizing
the health institutions are also more likely to be educated,
of higher socioeconomic status than the typical pregnant
woman in the community.
Dietary diversity was assessed based on responses
obtained from participants (e.g. dietary recall) during the
pregnancy and this depended on memory and their ability
to recall accurately. Recall bias could not be ruled out
completely. However, methods used in assessing dietary
diversity are useful for ranking individuals but do notnecessarily permit exact assessments of absolute nutrient
intake.
The study also relied partly on secondary data about
participants recorded by health professionals during the
pregnancy. Therefore any error in measurements,
readings or recordings of these parameters and indices
will reflect in the results. However with the level of
professionalism of health workers in the institutions
involved in the study, this is expected to be minimal. The
cross-sectional study design used to collect data also
makes it difficult to demonstrate cause-and-effect
relationships.
CONCLUSION
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In the present study, there was statistically significant
association between maternal DDS and anaemia in
pregnancy. The content of ANC, as well as dietary
diversity of women had positive effect on Hb in the third
trimester and so women should be educated on the need
for improved quality diets as well as quality and content
of ANC services in the health facilities.
The study findings suggest the need to strengthen
interventions that focus on improving the consumption of
diversified foods particularly during pregnancy.
Additionally, anaemia was higher with increased parity
levels and among women who initiated ANC late. This
implies the need to target interventions to these vulnerable
groups of women.
ACKNOWLEDGMENT
The authors wish to express their profound gratitude to all
the study participants. We are also grateful to the
administrators and midwives of Tamale Teaching Hospital,
Tamale West Hospital, Tamale Central Hospital and SDA
Hospital for granting us permission to interview thepregnant women admitted in their labour wards.
Conflict of Interest: Nil
REFERENCES
1. Horton R. Maternal and child undernutrition: an
urgent opportunity. Lancet. 2008;371(9608):179.
2. DeMaeyer E, Adiels-Tegman M. The prevalence of
anemia in the world. World Health Stat Q
1985;38:302-16.
3. Omigbodun AO. Recent trends in the management of
anaemia in pregnancy Tropical Journal of Obstetrics
and Gynaecology. 2004;21 (1): 1–3.
4. Komolafe JO, Kuti O, Oni O, Egbewale BE.
Sociodemographic characteristics of anaemic
gravidae at booking: a preliminary study at Llesha,
Western Nigeria Nigerian Journal of Medicine.
2005;14 (2): 151–54.
5. van den Broek NR, Letsky EA. Etiology of anemia in
pregnancy in south Malawi The American Journal of
Clinical Nutrition. 2000;72 (1): 247–56.
6. Adinma JIB, Ikechebelu JI, Onyejimbe UN, Amilo G,
Adinma E. Influence of antenatal care on the
haematocrit Value of pregnant Nigerian Igbo WomenTropical Journal of Obstetrics and Gynaecology.
2002;19 (2):68-70.
7. Ghana Statistical Service (GSS), Ghana Health
Service (GHS), ICF Macro. Ghana Demographic and
Health Survey (GDHS) 2008. Accra, Ghana: GSS,
GHS, and ICF Macro.;2009;
8. WHO. Worldwide Prevalence of Anemia: WHO Global
Database of Anaemia. Geneva: World Health
Organization;2008.
9. WHO. Physical status: the use and interpretation of
anthropometry. Report of a WHO Expert Committee.
Geneva: World Health Organization;1995.
10. Barker D. The malnourished baby and infant. Brit Med
Bull. 2001;60:69-88.
11. Vyas S, Kumaranayake L. Constructing socio-
economic status indices: how to use principal
components analysis. Health Policy Plan 2006;
21:459–68.
12. Filmer D, Pritchett LH. Estimating wealth effects
without expenditure data—or tears: an application to
educational enrollments in states of India.
Demography 2001; 38:115-32.
13. Rutstein SO, Johnson K. DHS Comparative Reports
6: The DHS Wealth Index. Calverton, Maryland,
USA: ORC Macro, MEASURE DHS;2004; 6:4-10.
14. Howe LD, Hargreaves JR, Huttly SRA. Issues in the
construction of wealth indices for the measurement of
socio-economic position in low-income countries.
Emerging Themes in Epidemiology 2008; 5:3
15. Mockenhaupt FP, Rong B, Gunther M, et al. Anaemia
in pregnant Ghanaian women: importance of malaria,
iron deficiency and haemoglobinopathies.
Transactions of the Royal Society of Tropical
Medicine and Hygiene. 2000;94:477-83.
16. McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist
B. Worldwide prevalence of anaemia, WHO vitaminand mineral nutrition information system, 1993–2005.
Public Health Nutr 2009;12:444.
17. Ghana Statistical Service (GSS), Ghana Health
Service (GHS), ICF International. Ghana
Demographic and Health Survey. Accra, Ghana:
GSS, GHS, ICF International.;2015;6: 30-31
18. UNICEF. Multiple Indicator Cluster Survey (MICS)
Accra: UNICEF;2011.
19. Samuel TM, Thomas T, Finkelstein J, et al. Correlates
of anaemia in pregnant urban South Indian women: a
possible role of dietary intake of nutrients that inhibit
iron absorption. Public Health Nutr 2013;16(2):316-
24.
20. Galloway R, Dusch E, Elder L, et al. Women’s
perception of iron deficiency and anaemia prevention
and control in eight developing countries Social
Science and Medicine 2002;55:529–44.
21. Clerk CA. Efficacy of sulphadoxine-pyrimethamine
and amodiaquine alone or in combination as
intermittent preventive treatment in pregnancy in the
Kassena-Nankana district of Ghana: a randomized
controlled trial London, University of London; 2007;
PhD Thesis.
22. Kedir H, Berhane Y, Worku A. Khat Chewing and
Restrictive Dietary Behaviors Are Associated with Anemia among Pregnant Women in High Prevalence
Rural Communities in Eastern Ethiopia. PLoS ONE
2013; 8(11):78601. .
23. Abriha A, Yesuf ME, Wassie MM. Prevalence and
associated factors of anemia among pregnant women
of Mekelle town: a cross sectional study BMC
Research Notes. 2014;7:888.
24. Gebremedhin S, Enquselassie F. Correlates of
anemia among women of reproductive age in
Ethiopia: evidence from Ethiopian DHS. Ethiopian J
Health Dev 2005; 25(1):22–30.
25. Baig-Ansari N, Badruddin SH, Karmaliani R, et al.
Anemia prevalence and risk factors in pregnant
women in an urban area of Pakistan. Food Nutr Bull.
2008; 29(2):132–39.
8/20/2019 Ijmrhs Vol 4 Issue 4
16/193
755
Saaka et al., Int J Med Res Health Sci. 2015;4(4):749-755
26. Karaoglu L, Pehlivan E, Egri M, et al. The prevalence
of nutritional anemia in pregnancy in an east
Anatolian Province, Turkey. Health. 2010;10(1):329.
27. Jemal HNH, Urga K. Iron deficiency anemia in
pregnant and lactating mothers in rural Ethiopia. East
Afr Med J 1999; 76:618–22.
28. FAO. Guidelines for measuring household and
individual dietary diversity. Rome, Italy: Food and
Agriculture Organization of the United Nations; 2011;
4: 1-31
29. Wen LM, Flood VM, Simpson JM, Rissel C, Baur LA.
Dietary behaviours during pregnancy: findings
from first -time mothers in southwest Sydney,
Australia. Int J Behav Nutr Phys Act 2010;7(13):1–
7.
30. Neggers Y, Goldenberg RL. Some thoughts on
body mass index, micronutrient intakes and
pregnancy outcome. J Nutr. 2003;133(2):1737-40.
31. Patil R, Mittal A, Vedapriya D, Khan MI, Raghavia M.
Taboos and misconceptions about food during
pregnancy among rural population of
Pondicherry. Calicut Med J 2010;8(2):4.32. Meena G. Associations Between Maternal
Nutritional Characteristics and the Anthropometric
Indices of Their Full -term and Pre-term Newborns.
Pak J Nutr 2012;4(11):343–49.
33. Clerk CA, Bruce J, Greenwood B, Chandramohan D.
The epidemiology of malaria among pregnant women
attending antenatal clinics in an area with intense and
highly seasonal malaria transmission in northern
Ghana Tropical Medicine and International Health
2009; 14 ( 6): 688–95.
34. Adinma JIB, Ikechebelu JI, Onyejimbe UN, Amilo G,
Adinma E. Influence of antenatal care on the
haematocrit Value of pregnant Nigerian Igbo Women.
Tropical Journal of Obstetrics and Gynaecology.
2002;19 (2): 68–70.
35. Al-Farsi YM, Brooks DR, Werler MM, Cabral HJ, Al-
Shafei MA, Wallenburg HC. Effect of high parity on
occurrence of anemia in pregnancy: a cohort study.
BMC Pregnancy Childbirth 2011; 11:7.
36. Uche-Nwachi EO, Odekunle A, Jacinto S, et al.
Anaemia in pregnancy: associations with parity,
abortions and child spacing in primary healthcare
clinic attendees in Trinidad and Tobago. Afr Health
Sci 2010; 10(1):66-70.
37. Bukar M, Audu BM, Sadauki HM, Elnafaty AU,Mairiga AG. Prevalence of iron deficiency and
megaloblastic anaemia at booking in a secondary
Health facilty in North Eastern Nigeria. Nigerian
Journal of Medicine. 2009; 50 (2):33–37.
8/20/2019 Ijmrhs Vol 4 Issue 4
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Available online at: www.ijmrhs.com DOI: 10.5958/2319-5886.2015.00147.2
Research article Open Access
CLINICAL PATTERN AND EFFECT OF CO-MORBIDITIES IN THE ETIOPATHOGENESIS
OF INCISIONAL HERNIAS
*Murali U¹, Thakre N D²
INTRODUCTION
Incisional hernia is a problem of magnitude. It is also a
socioeconomic problem. For the individual patient
incisional hernia is an unexpected and hindering
complication, which can influence daily life in such a
manner that he or she could be consider disabled.
Repeated admissions and operations have a major impact
on the patient. When subsequent hernia repair does not
solve the problem, but results in recurrence or
complications, a patient’s quality of life may be seriously
affected.
Incisional hernia occurs in about 2-19% of patients after
various incisions[1, 2, 3, 4]
. When the scar has a defect, the
abdominal contents may start protruding through it, due to
intra-abdominal pressure. Certain conditions like chronic
cough, chronic constipation, urinary obstruction, obesity,
pulmonary disease, repeated pregnancies and post-
operative abdominal distension may further increase the
pressure unwantedly and increase the chance of incisionalhernia
[5, 6]. Wound infection is probably an important risk
factor for the development of incisional hernia[7]
and
wound dehiscence[8, 1, 2]
. In spite of all precautions during
surgery and meticulous repairs to cure them, a number of
cases of incisional hernias are being reported with failures
of repairs leading to “Recurrent incisional hernia”.
Therefore, prevention of incisional hernia is warranted.
Our aim was to study the aetiopathogenesis and effects of
co-morbidities on the clinical course of incisional hernias
and repair.
MATERIALS & METHODS
Study design: It was a cross sectional, Descriptive study
Locus of study: The study carried out in patients of
Jawaharlal Nehru Hospital (JNH), Rose Belle, Mauritius
between December 2010 to September 2012.
Sample size: A total number of 38 cases were studied.
Inclusion criteria: All patients of both genders aged
above 25 years with incisional hernia who came to JNH
were included in this study.
Exclusion criteria: Patients with recurrent inguinal hernia
were excluded as they were categorized as primarily
hernias of different aetiopathology.
Ethics: The protocol and proforma for collection of data as
well for the study was approved by the ethical committee.
Methodology:
Detailed history pertaining to the surgery which later on
led to the incisional hernia was recorded; more stress was
laid on the predisposing factors and co-morbidities at the
time of operation. Thorough work up of all patients
included a complete physical examination, weight inkilograms, height in meters, size of defect and
investigations like haemogram, X-ray chest, ECG, renal
profile and echocardiography.
Patients were evaluated for co-morbidities like asthma,
chronic obstructive pulmonary diseases (COPD), diabetes
mellitus (DM), morbid obesity, hypertension (HTN) and
malignancies at the time of first operation. Body mass
index (BMI) at the time of previous operation which led to
incisional hernia was also recorded.
Out of 38 patients in this study 22 patients were operated
and hernia repaired. These patients were studied for their
postoperative recovery and complications. Special
emphasis was laid on the date of the operation which led
to hernia formation and the actual date when the patient
detected hernia. These dates gave information about the
ABSTRACT
Background: Incisional hernia is a common iatrogenic complication of
abdominal surgery and is a cause of unwanted morbidity. The study was
reported for the first time from Republic of Mauritius. Aims & Objectives: The
objective of the study was to analyze the clinical pattern and effect of co-
morbidities on the clinical course of incisional hernias and repair. Methods: The
study is a cross sectional study conducted at a tertiary care hospital for over 22
months. 38 patients with incisional hernia were studied with special emphasis
laid on the predisposing factors and co-morbidities at the time of hernia repair.
Results: In this study the incidence of incisional hernia was prevalent in females
and occurrence was 3 times more than males. All hernias in females were the
result of a gynaecological operation. 68% (26 out of 38 patients studied) of
hernias were reported within 2 years of gynaecological operation. Majority of
patients presented with swelling and pain related to scar. Twenty two out of thirty eight were operated and hernia repaired. Obesity was found to be the
most important factor when the effects of co-morbidities were studied. Fifteen
out of thirty eight (39.47%) patients came under the category of morbidly obese.
Conclusion: In patients with recurrent hernia control of obesity and other co-
morbidities before the attempt to repair hernia can be decisive.
ARTICLE INFO
Received: 11th May 2015Revised : 2nd Jun 2015Accepted: 23rd Jul 2015
Authors details:1,2
Department of
General Surgery, D Y Patil Medical
College, Mauritius
Corresponding author: Murali U
Department of General Surgery, D Y
Patil Medical College, Mauritius
Email: [email protected]
Keywords: Incisional hernia,
Complications, Co-morbidity, Obesity .
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exact time period between surgery and the hernia. In most
of the cases the information related to the type of previous
surgery and methods of closure adopted were also traced
from their earlier records.
Statistical analysis: Data was analyzed using descriptive
statistical principles (like mean, proportions and
percentages) with SPSS 19 Package analyzed and
different findings were compared with the available
literature and discussed.
RESULTS
Out of 38 patients in the study, 29 patients were female
while 9 were male. The age group of the patients varied
from 29 to 82 years. Incidence was highest in the age
group ranging from 50 to 70 years. Regarding the
occupation of patients, out of 29 females majority of them
(22) were house-wives.
Most of the patients (15) presented with swelling, followed
by pain and swelling in about 11 of them, pain alone in 9
cases and rest (3) with associated symptoms of
constipation. Only two out of 38 came with features
suggestive of intestinal obstruction. Incisional hernia was
more common after midline incision (76.31%). Out of the
38 patients studied the commonest incisions responsible,
for the hernia were infra umbilical midline (16) and supra
umbilical midline (13) (Table – 1).
Lower segment caesarean section (LSCS) was the
commonest operation responsible for the incisional hernia
in 18 cases of this study followed by emergency
laparotomy (Table – 1). The dimension of the defect was
studied in only 30 patients. The commonest defect size
was 12 sq. cm. observed in 7 followed by 8 sq.cm in 6 out
of 30 patients studied (Table – 1). The time period
between the appearance of hernia and the operation
responsible for it showed that 26 out of 38 patients
reported about their hernia within 2 years of operation
(68.42%) (Table – 2).
Morbid obesity was the commonest co-morbidity amongst
the patients (15) studied followed by hypertension in 14
patients (Table – 3). Out of the 38 patients studied, 28
(73.68%) patients were obese (BMI over 25 kg/m2). Out of
these 28 patients, 15 came under the category of morbidly
obese with 3 in class III (BMI over 40 kg/m2), 4 in class II
(BMI over 35 kg/m2) and 8 in class I (BMI over 30 kg/m2).
Out of 38 patients, 22 were operated and repair of hernia
carried out. There was no recurrence or complicationsobserved in our study. There was no mortality.
Table 1: Operations and Incisions causing hernia with Defect sizes
Operation No. of cases Incision No. of cases Defect size No. of cases
LSCS 18 McBurney 2 2 sq.cm 3
Cholecystectomy 3 Kocher’s 2 2.25sq.cm 1
Hysterectomy 2 Infra umbilical transverse 2 4 sq.cm 4
Appendicectomy 2 Infra umbilical midline 16 6 sq.cm 5
Expl. Laparotomy 7 Supra umbilical midline 13 8 sq.cm 6
Laparotomy 1 Supra umbilical transverse 1 12 sq.cm 7
Umbilical hernia 4 Lumbar 1 15 sq.cm 2
Nephrolithotomy 1 Para median 1 24 sq.cm 2
Table 2: Onset of hernia
Time interval Number of cases
0 to 6 months 9
6 months to 1 year 8
1 year to 2 year 9
2 year to 3 year 1
3 year to 4 year 3
4 year to 5 year 3
5 years onwards 5
Table 3: Types of Co-morbidities
Co-morbidities Number of
cases
Percentage
Diabetes mellitus 7 18.42
Hypertension 14 36.84
Morbid obesity 15 39.47
Ischaemic heart disease 4 10.52
Hyperthyroidism 1 2.63
Bronchial asthma 4 10.52
Neurological disorder 2 5.36
Malignant disease 1 2.63
DISCUSSION
38 cases of incisional hernia admitted in JNH, Rose Belle,
Mauritius for treatment were included in this study
between December 2010 to September 2012. The mean
age of patients of incisional hernia in our study was 56.02
years. Ellis et al[9]
in their study observed a mean age of
49.4 years. The youngest patient in our study was 29
years and the oldest was 82 years. The sex ratio of
incisional hernia among the cases studied was 1:3 (M: F),
showing a female preponderance. This can be attributed
to the laxity of abdominal muscles due to multiple
pregnancies and an increased incidence of obesity in
females. Most of the women were housewives which show
that incisional hernias were more common in women.
Thirty nine percent (39.4%) of patients presented with
abdominal swelling without any complaint of pain or
discomfort due to hernia. Two patients (5.26%) presentedwith complication, i.e. one with acute intestinal obstruction
which needed an exploratory laparotomy with resection
and anastomosis of small bowel for gangrene and repair
of hernia. The other was a sub-acute case of intestinal
obstruction, treated conservatively and hernia repair done
later on. This can be compared with Mudge and Hughes[4]
series (14%).
In our study 42.1% of incisional hernia occurred in midline
infra umbilical incisions. This may be because of following
features:
1. Intra-abdominal hydrostatic pressure is higher in
lower abdomen compared to upper abdomen, in erect
position i.e. 20cm of water and 8cm of water
respectively.
2. Absence of posterior rectus sheath below the arcuate
line.
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Midline infra umbilical incisions were used mainly in
females for LSCS and abdominal hysterectomy, which
have poor abdominal wall musculature. This can be
comparable with that of Goel and Dubey[10]
studies
(44.6%).
Fifty two percent of cases (52%) occurred following
gynaecological procedures (abdominal hysterectomy and
LSCS). Suhas and Rigved[11]
in their studies noted 68%
incidence and other studies[10]
noted 28.76% incidence
following gynaecological procedures. Higher incidence in
our study similar to studies[11]
may be because most of
these procedures were done through lower midline
incisions.
In our study 23.68% of patients developed incisional
hernia within 6 months of previous surgery. These early
hernias can be attributed to a possibly faulty technique of
repair. 21.05% of patients developed within 6-12 months.
23.68% of patients developed within 12-24 months.
31.57% of patients developed incisional hernia after 2
years of the previous surgery. All the hernias which were
reported by patients within 2 years come under the
category of early incisional hernia, the defect must havestarted at the initial phase of healing but was detected little
later. Most studies showed incidence within a year of
follow-up of patients except for studies of Ellis et al[9]
which showed an incidence of 5.8% for a follow-up period
of 2.5 – 5.5 years in 363 patients, similar to present study.
Considering the dimension of defect in 30 patients, 23.3%
of patients were found to have hernia defect of up to 12
sq. cm. While most others showed a defect size of 2sq.cm
to 8 sq. cm. Previous studies[1]
show that the size of the
fascial defect should dictate the selection of the most
appropriate method of hernia repair.
One patient with diabetes mellitus developed an
intractable infection which needed removal of the mesh. It
is one of the most dreaded complications, as it adds to the
morbidity and leads to recurrent hernia invariably. 11
patients (28.9%) in this study had history of multiple
attempts of repair. This can be compared with Ellis et al[12]
series (25%). Co-morbidities which were encountered in
the patients were namely obesity (15) , hypertension (14),
diabetes mellitus (7), ischaemic heart disease , bronchial
asthma (4 each) and neurological disorder (2). One of the
patients had hyperthyroidism and one patient had colonic
malignancy. Out of all above conditions, morbid obesity
(39.47%) was the commonest co-morbidity in the patients
studied. This can be compared to the results reported byNikhil et al (40%)
[13].
In our study Body mass index (BMI) of more than 30 was
considered as morbid obesity. 15 out of 38 patients were
morbidly obese with BMI of more than 30. In this study 11
patients with recurrent incisional hernia formed a major
group. Out of these 11 patients 6 (54%) were morbidly
obese with BMI of more than 40 (Morbid obesity class III).
Hernia repair was carried out in 22 cases. The types of
repair done were polypropylene mesh repair in 12 patients
and anatomical repair in 10 patients. Non-absorbable
suture material was used to close the fascial layer. In our
study no complications or recurrences were observed.
This can be compared to Usher [14] who reported zero
percent recurrence in 48 patients who were treated by
polypropylene mesh repair. Certain studies show
recurrence rates up to 43% after anatomical suture repair
and 24% after mesh repair [15]
. Thus the recurrence rate
varies in different studies but all studies favor mesh repair
to decrease the rate of recurrence. The merit of our study
was that there was no mortality.
CONCLUSION
Thirty eight cases of Incisional hernias were studied with
respect to its clinical pattern aspects, effects of its co-
morbidities and efficacy of its repair. The following
conclusions were drawn: Obesity with deposition of fat in
the lower abdomen is an important factor in causation of
recurrent hernia. Operation for an incisional hernia should
be undertaken after reduction of body weight. The use of
midline incision should be restricted, to operations in
which unlimited access to abdominal cavity is necessarily
required. Non absorbable suture material should be used
for repair of facial layer. All co-morbidities should be
corrected before a planned operation.
ACKNOWLEDGEMENTS
We wish to express our thanks to Dr.R.K.Sharma, Dean,
Padmashree Dr. D. Y. Patil Medical College, Mauritius for
his support and encouragement. We are thankful to our
earlier HOD, Dr. Sanjay. M. Date for his contribution to
research article. We also thank Dr.S. L. Bodhankar for his
assistance in the preparation of manuscript.
Conflict of Interest: Nil
REFERENCES
1. Santora TA, Roslyn JJ. Incisional hernia.Surgclin
north am 1993; 73(3): 557-70.
2. Eisner L, Harder F. Incisional hernia. Chirurg 1997;
68(4): 304-9.
3. Hodgson NC, Malthaner R A, Ostbye T. The search
for an ideal method o